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Health History & Wellness Intake

please read and complete this health waiver form before participating in studio activites.

First name

Last name

Phone

Email

Date of birth

Month

Day

Year

Emergency Contact Information

Emergency contact name & relationship

Emergency contact phone

Current Health Status

Are you currently under any physician's care?

Medical conditions or injuries

Current medications

Are you currently experiencing pain?

Please do your best to locate the depth and level of pain you experience at any level of consistency 🩵

I have consulted with my wellness team regarding my participation in Pilates activities (if applicable based on my health status, under certain individual circumstances, Centered Motion may require written medical clearance from a licensed healthcare provider before participation or continuation of training)

How active are you regularly?

Assumption of Risk and Release

By participating in Pilates classes and activities, I understand and acknowledge the following:

I understand that Pilates involves physical activity and carries inherent risks of injury, including but not limited to muscle strains, sprains, and other physical injuries

I voluntarily assume all risks associated with participation in Pilates activities and release the studio, instructors, and staff from any liability for injuries or damages

I agree to follow all safety instructions provided by instructors and will not participate in any activity beyond my physical capabilities

I understand that I should immediately inform the instructor if I experience any pain or discomfort during class

I agree to the studio's policies regarding cancellations, make-up classes, and general conduct

By signing this document, I acknowledge the inherent risks and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation. I hereby waive and release the business, its owners, and its staff from any and all liability, past, present, and future, relating to the services provided.

Participant signature

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Date of agreement

Month

Day

Year