Registration Form

Health and safety questionnaire and registration form - PAR-Q

Full Name

Phone

Occupation

Age

Address

Do you suffer or have suffered from the following? Please tick, if yes please provide information in the box below the questions.

Are you presently taking any form of medication?

Yes

Have you ever had asthma, chronic bronchitis or any other chest ailments?

Yes

Are you recuperating from a recent illness/operation or injury?

Yes

Have you any medical condition that we should be aware of?

Yes

Is there any history of heart disease in your immediate family (under the age of 55)?

Yes

If answered yes to any of the questions above, please provide some detail below and any other medical history that you feel I should be aware of:

Please provide some information on your current fitness, strength abilities, occupation and lifestyle habits (for example to spend a lot of time in the day sitting at a desk):

Please provide the contact details of an emergency contact including their relationship to you:

PLEASE NOTE: If you answered YES to any of the questions above, you are advised to seek medical advice/approval before commencing an exercise induction or exercise programme or consult further with your instructor.

I have been informed both verbally and in writing that if I answer YES to any of the questions above in this questionnaire, I should seek medical advice/approval before commencing an exercise programme and/or induction. If I wish to continue without such advice I do so entirely at my own risk. I confirm that I have read, fully understood and answered the above questions honestly. I understand that the Instructor and any of its employees cannot be held responsible for any injuries or ill health arising from my participation in the exercise programme.

Pilates informed consent form

I hereby state that I have read, understood and answered honestly the questions on the PAR-Q. I wish to participate in physical activities that will include a Pilates warm-up preparation phase involving standing and lying exercises and a main mat-based Pilates session with floor-based exercises. These could involve use of small equipment such as a resistance band, blocks, foam rollers or Pilates rings. The session will also include flexibility exercises.

I realise that in participating in these activities I may be at risk of injury and even the possibilty of death. I hereby confirm that I am participating voluntarily.

Signature

Print Name

Date completed

Which class are you booking for and what date does the block start? (for example : Thursday 18:45, 29th February 2024)

Photography and Video

If you consent to being used in photographs and videos taken during my Pilates class for the use of promotion material, then please include your details below. You may revoke this authorization at any time by notifying me. The revocation will not affect any actions taken before the receipt of this written notification. Images will be stored in a secure location and only authorized individuals will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.

Cosent for photography and video

Yes, consent given

No, consent not given

Thank you for registering.