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Client Intake Form & Waiver of Liability

In signing below I agree that The Pilates Place is in no way responsible for the safe keeping of my personal belongings while I attend class. I understand that classes at The Pilates Place may be physically strenuous and I voluntarily participate in them with full knowledge that there is risk of personal injury, property, loss or death. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against The Pilates Place or its members for any personal injury, property. damage/loss, or wrongful death, whether caused by negligence or otherwise. The above statement also applies to The Belmont Athletic Club, Inc., and course sessions LLC.

 

Please be advised that certain health restrictions may require you to obtain medical clearance from your position before training can begin.

 

Cancellation Policy

Any waivers for optimum results, keeping a regular schedule is advised. All cancellations must be made 24 hours in advance, or the session will be charged. There are NO refunds except in cases of physical disability. Beginning any exercise program should be with your physicians approval.


Today's Date: September 8, 2024

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Age Acknowledgment*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
I have been offered a copy of this waiver*
No
Yes
Please check any current conditions
Diabetes
Epilepsy
High cholesterol
Asthma
Arthritis
High blood pressure
Heart conditions
Pregnancy
Have you injured or had pain in any of the following areas?
Neck
Upper back
Shoulders
Elbows
Lower back
Hips
Wrist
Knees

If yes, please explain:
What is your current exercise level? *
none
2-3 times per week
4-5 times per week

What type of exercise?
How did you hear about us?*
Google
Instagram
Facebook
Referral
Belmont
ClassPass

Other:
What are your exercise goals?
Increase strength
Flexibility
Weight loss
Cardiovascular conditioning
Posture
Stress reduction

Other:
What services are you interested in?
Reformer classes
Privates
Semi-privates
Mat classes
Cardio pilates

Other:

Check the appropriate response. Read all questions thoroughly:

Has your doctor ever told you you have a heart problem? *
No
Yes
Has your doctor ever told you you have high blood pressure? *
No
Yes
Have you ever had a stroke or heart attack? *
No
Yes
Have you ever had pain in your chest *
No
Yes
Do you ever feel faint or have dizzy spells? *
No
Yes
Have you had surgery in the last six months? *
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
I have been offered a copy of this waiver*
No
Yes
Please check any current conditions
Diabetes
Epilepsy
High cholesterol
Asthma
Arthritis
High blood pressure
Heart conditions
Pregnancy
Have you injured or had pain in any of the following areas?
Neck
Upper back
Shoulders
Elbows
Lower back
Hips
Wrist
Knees

If yes, please explain:
What is your current exercise level? *
none
2-3 times per week
4-5 times per week

What type of exercise?
How did you hear about us?*
Google
Instagram
Facebook
Referral
Belmont
ClassPass

Other:
What are your exercise goals?
Increase strength
Flexibility
Weight loss
Cardiovascular conditioning
Posture
Stress reduction

Other:
What services are you interested in?
Reformer classes
Privates
Semi-privates
Mat classes
Cardio pilates

Other:

Check the appropriate response. Read all questions thoroughly:

Has your doctor ever told you you have a heart problem? *
No
Yes
Has your doctor ever told you you have high blood pressure? *
No
Yes
Have you ever had a stroke or heart attack? *
No
Yes
Have you ever had pain in your chest *
No
Yes
Do you ever feel faint or have dizzy spells? *
No
Yes
Have you had surgery in the last six months? *
No
Yes
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
I have been offered a copy of this waiver*
No
Yes
Please check any current conditions
Diabetes
Epilepsy
High cholesterol
Asthma
Arthritis
High blood pressure
Heart conditions
Pregnancy
Have you injured or had pain in any of the following areas?
Neck
Upper back
Shoulders
Elbows
Lower back
Hips
Wrist
Knees

If yes, please explain:
What is your current exercise level? *
none
2-3 times per week
4-5 times per week

What type of exercise?
How did you hear about us?*
Google
Instagram
Facebook
Referral
Belmont
ClassPass

Other:
What are your exercise goals?
Increase strength
Flexibility
Weight loss
Cardiovascular conditioning
Posture
Stress reduction

Other:
What services are you interested in?
Reformer classes
Privates
Semi-privates
Mat classes
Cardio pilates

Other:

Check the appropriate response. Read all questions thoroughly:

Has your doctor ever told you you have a heart problem? *
No
Yes
Has your doctor ever told you you have high blood pressure? *
No
Yes
Have you ever had a stroke or heart attack? *
No
Yes
Have you ever had pain in your chest *
No
Yes
Do you ever feel faint or have dizzy spells? *
No
Yes
Have you had surgery in the last six months? *
No
Yes
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
I have been offered a copy of this waiver*
No
Yes
Please check any current conditions
Diabetes
Epilepsy
High cholesterol
Asthma
Arthritis
High blood pressure
Heart conditions
Pregnancy
Have you injured or had pain in any of the following areas?
Neck
Upper back
Shoulders
Elbows
Lower back
Hips
Wrist
Knees

If yes, please explain:
What is your current exercise level? *
none
2-3 times per week
4-5 times per week

What type of exercise?
How did you hear about us?*
Google
Instagram
Facebook
Referral
Belmont
ClassPass

Other:
What are your exercise goals?
Increase strength
Flexibility
Weight loss
Cardiovascular conditioning
Posture
Stress reduction

Other:
What services are you interested in?
Reformer classes
Privates
Semi-privates
Mat classes
Cardio pilates

Other:

Check the appropriate response. Read all questions thoroughly:

Has your doctor ever told you you have a heart problem? *
No
Yes
Has your doctor ever told you you have high blood pressure? *
No
Yes
Have you ever had a stroke or heart attack? *
No
Yes
Have you ever had pain in your chest *
No
Yes
Do you ever feel faint or have dizzy spells? *
No
Yes
Have you had surgery in the last six months? *
No
Yes
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
I have been offered a copy of this waiver*
No
Yes
Please check any current conditions
Diabetes
Epilepsy
High cholesterol
Asthma
Arthritis
High blood pressure
Heart conditions
Pregnancy
Have you injured or had pain in any of the following areas?
Neck
Upper back
Shoulders
Elbows
Lower back
Hips
Wrist
Knees

If yes, please explain:
What is your current exercise level? *
none
2-3 times per week
4-5 times per week

What type of exercise?
How did you hear about us?*
Google
Instagram
Facebook
Referral
Belmont
ClassPass

Other:
What are your exercise goals?
Increase strength
Flexibility
Weight loss
Cardiovascular conditioning
Posture
Stress reduction

Other:
What services are you interested in?
Reformer classes
Privates
Semi-privates
Mat classes
Cardio pilates

Other:

Check the appropriate response. Read all questions thoroughly:

Has your doctor ever told you you have a heart problem? *
No
Yes
Has your doctor ever told you you have high blood pressure? *
No
Yes
Have you ever had a stroke or heart attack? *
No
Yes
Have you ever had pain in your chest *
No
Yes
Do you ever feel faint or have dizzy spells? *
No
Yes
Have you had surgery in the last six months? *
No
Yes
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
I have been offered a copy of this waiver*
No
Yes
Please check any current conditions
Diabetes
Epilepsy
High cholesterol
Asthma
Arthritis
High blood pressure
Heart conditions
Pregnancy
Have you injured or had pain in any of the following areas?
Neck
Upper back
Shoulders
Elbows
Lower back
Hips
Wrist
Knees

If yes, please explain:
What is your current exercise level? *
none
2-3 times per week
4-5 times per week

What type of exercise?
How did you hear about us?*
Google
Instagram
Facebook
Referral
Belmont
ClassPass

Other:
What are your exercise goals?
Increase strength
Flexibility
Weight loss
Cardiovascular conditioning
Posture
Stress reduction

Other:
What services are you interested in?
Reformer classes
Privates
Semi-privates
Mat classes
Cardio pilates

Other:

Check the appropriate response. Read all questions thoroughly:

Has your doctor ever told you you have a heart problem? *
No
Yes
Has your doctor ever told you you have high blood pressure? *
No
Yes
Have you ever had a stroke or heart attack? *
No
Yes
Have you ever had pain in your chest *
No
Yes
Do you ever feel faint or have dizzy spells? *
No
Yes
Have you had surgery in the last six months? *
No
Yes
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
I have been offered a copy of this waiver*
No
Yes
Please check any current conditions
Diabetes
Epilepsy
High cholesterol
Asthma
Arthritis
High blood pressure
Heart conditions
Pregnancy
Have you injured or had pain in any of the following areas?
Neck
Upper back
Shoulders
Elbows
Lower back
Hips
Wrist
Knees

If yes, please explain:
What is your current exercise level? *
none
2-3 times per week
4-5 times per week

What type of exercise?
How did you hear about us?*
Google
Instagram
Facebook
Referral
Belmont
ClassPass

Other:
What are your exercise goals?
Increase strength
Flexibility
Weight loss
Cardiovascular conditioning
Posture
Stress reduction

Other:
What services are you interested in?
Reformer classes
Privates
Semi-privates
Mat classes
Cardio pilates

Other:

Check the appropriate response. Read all questions thoroughly:

Has your doctor ever told you you have a heart problem? *
No
Yes
Has your doctor ever told you you have high blood pressure? *
No
Yes
Have you ever had a stroke or heart attack? *
No
Yes
Have you ever had pain in your chest *
No
Yes
Do you ever feel faint or have dizzy spells? *
No
Yes
Have you had surgery in the last six months? *
No
Yes
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
I have been offered a copy of this waiver*
No
Yes
Please check any current conditions
Diabetes
Epilepsy
High cholesterol
Asthma
Arthritis
High blood pressure
Heart conditions
Pregnancy
Have you injured or had pain in any of the following areas?
Neck
Upper back
Shoulders
Elbows
Lower back
Hips
Wrist
Knees

If yes, please explain:
What is your current exercise level? *
none
2-3 times per week
4-5 times per week

What type of exercise?
How did you hear about us?*
Google
Instagram
Facebook
Referral
Belmont
ClassPass

Other:
What are your exercise goals?
Increase strength
Flexibility
Weight loss
Cardiovascular conditioning
Posture
Stress reduction

Other:
What services are you interested in?
Reformer classes
Privates
Semi-privates
Mat classes
Cardio pilates

Other:

Check the appropriate response. Read all questions thoroughly:

Has your doctor ever told you you have a heart problem? *
No
Yes
Has your doctor ever told you you have high blood pressure? *
No
Yes
Have you ever had a stroke or heart attack? *
No
Yes
Have you ever had pain in your chest *
No
Yes
Do you ever feel faint or have dizzy spells? *
No
Yes
Have you had surgery in the last six months? *
No
Yes
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
I have been offered a copy of this waiver*
No
Yes
Please check any current conditions
Diabetes
Epilepsy
High cholesterol
Asthma
Arthritis
High blood pressure
Heart conditions
Pregnancy
Have you injured or had pain in any of the following areas?
Neck
Upper back
Shoulders
Elbows
Lower back
Hips
Wrist
Knees

If yes, please explain:
What is your current exercise level? *
none
2-3 times per week
4-5 times per week

What type of exercise?
How did you hear about us?*
Google
Instagram
Facebook
Referral
Belmont
ClassPass

Other:
What are your exercise goals?
Increase strength
Flexibility
Weight loss
Cardiovascular conditioning
Posture
Stress reduction

Other:
What services are you interested in?
Reformer classes
Privates
Semi-privates
Mat classes
Cardio pilates

Other:

Check the appropriate response. Read all questions thoroughly:

Has your doctor ever told you you have a heart problem? *
No
Yes
Has your doctor ever told you you have high blood pressure? *
No
Yes
Have you ever had a stroke or heart attack? *
No
Yes
Have you ever had pain in your chest *
No
Yes
Do you ever feel faint or have dizzy spells? *
No
Yes
Have you had surgery in the last six months? *
No
Yes
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
I have been offered a copy of this waiver*
No
Yes
Please check any current conditions
Diabetes
Epilepsy
High cholesterol
Asthma
Arthritis
High blood pressure
Heart conditions
Pregnancy
Have you injured or had pain in any of the following areas?
Neck
Upper back
Shoulders
Elbows
Lower back
Hips
Wrist
Knees

If yes, please explain:
What is your current exercise level? *
none
2-3 times per week
4-5 times per week

What type of exercise?
How did you hear about us?*
Google
Instagram
Facebook
Referral
Belmont
ClassPass

Other:
What are your exercise goals?
Increase strength
Flexibility
Weight loss
Cardiovascular conditioning
Posture
Stress reduction

Other:
What services are you interested in?
Reformer classes
Privates
Semi-privates
Mat classes
Cardio pilates

Other:

Check the appropriate response. Read all questions thoroughly:

Has your doctor ever told you you have a heart problem? *
No
Yes
Has your doctor ever told you you have high blood pressure? *
No
Yes
Have you ever had a stroke or heart attack? *
No
Yes
Have you ever had pain in your chest *
No
Yes
Do you ever feel faint or have dizzy spells? *
No
Yes
Have you had surgery in the last six months? *
No
Yes
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
I have been offered a copy of this waiver*
No
Yes
Please check any current conditions
Diabetes
Epilepsy
High cholesterol
Asthma
Arthritis
High blood pressure
Heart conditions
Pregnancy
Have you injured or had pain in any of the following areas?
Neck
Upper back
Shoulders
Elbows
Lower back
Hips
Wrist
Knees

If yes, please explain:
What is your current exercise level? *
none
2-3 times per week
4-5 times per week

What type of exercise?
How did you hear about us?*
Google
Instagram
Facebook
Referral
Belmont
ClassPass

Other:
What are your exercise goals?
Increase strength
Flexibility
Weight loss
Cardiovascular conditioning
Posture
Stress reduction

Other:
What services are you interested in?
Reformer classes
Privates
Semi-privates
Mat classes
Cardio pilates

Other:

Check the appropriate response. Read all questions thoroughly:

Has your doctor ever told you you have a heart problem? *
No
Yes
Has your doctor ever told you you have high blood pressure? *
No
Yes
Have you ever had a stroke or heart attack? *
No
Yes
Have you ever had pain in your chest *
No
Yes
Do you ever feel faint or have dizzy spells? *
No
Yes
Have you had surgery in the last six months? *
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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