Registration FormAll information provided will be treated confidentially. Name of class participant First Name Last Name Name of parent/guardian if participant is under 18 years old First Name Last Name Email * Phone * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency contact and phone no. * Were you referred by a medical practitioner Yes No If yes, then whom? Do you have a referral letter? Yes No Occupation Sport/hobbies Does you work/sport involve: sitting for long periods? Yes No Driving? Yes No Standing? Yes No Bending? Yes No Lifting heavy weights? Yes No Other repetitive action? Are you pregnant or given birth in the last 6 months? Please note: it is inadvisable to do Pilates between weeks 0 and 14 of pregnancy (except by special arrangement with the instructor), or within 6 weeks of giving birth. Yes No Have you ever been recommended remedial exercises by a medical professional? Yes No If so, please describe Are there any movements that cause you pain (e.g. bending forward or to the side, raising your arms etc)? Yes No If so, please describe Do you wish to strengthen a particular area? Yes No If so, which? Do you, or have you suffered from any of the following: Diabetes? Yes No Epilepsy? Yes No Digestive problems? Yes No Asthma? Yes No Heart problems? Yes No Cancer? Yes No Osteoporosis? Yes No Arthritis? Yes No High/low blood pressure? Yes No Back, neck or shoulder problems? Yes No Any other relevant condition? Yes No If so, please describe Thank you for submitting your registration form.Please advise your instructor before commencing any class if any of the information you have provided changes.Close this browser to continue with your booking.
