Book a class today New Client IntakePlease complete the intake form below before registering for your first class Complete Now New Client Intake Full Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Telephone * (###) ### #### Email * Emergency Contact * (Name) Emergency Contact Telephone * (###) ### #### Health Questionaire * Have you currently or previously been diagnosed with any of the following health conditions? (check all that apply) Arthritis Back Pain Bowel/Bladder Changes Cancer Circulatory Disease Diabetes Dizziness Fainting Disorder Heart Disease Heart Attack Herniated Disk High Blood Pressure Hypoglycemia Hyperglycemia Numbness or Weakness Osteoporosis Osteoarthritis Pregnancy (currently) Seizure Disorder Shoulder Impingement Stenosis Thyroid Disorder Additional Information Is there any additional information related to your health or fitness level that you would like to share? Release of Liability Waiver * This is a release of liability and waiver of certain legal rights. Your signature hereto indicates your understanding of, and agreement to, the terms and conditions set forth herein. Read carefully before signing. IN CONSIDERATION for my being permitted to participate in any activities or services, in person and/or virtually, of Magic Circle Pilates, LLC (“MCPilates”) outlined herein, I agree to the following: I acknowledge that classes, services and activities of MCPilates, including, but not limited to, pilates (the “Activities”), involve inherent physical risks and hazards, and I understand the risks and hazards of the Activities. I understand that the Activities may require good physical conditioning and a degree of skill and knowledge, including, but not limited to, use of pilates-related equipment. I believe I possess good physical conditioning, and I have the degree of skill and knowledge necessary for me to engage in the Activities safely. My participation in the Activities is purely voluntary. I understand and acknowledge that MCPilates' representatives and service providers are not medical professionals and are not responsible for the diagnosis, treatment or management of my health conditions or injuries. MCPilates does not guarantee or promise any outcome or results regarding the use of any services or participation in any of the Activities. Any comments regarding the Activities are expressions of opinion only. I acknowledge and voluntarily assume the risk of injury, accident or death which may arise from the Activities. I, for myself, my heirs, successors, executors, and subrogees, hereby KNOWINGLY AND INTENTIONALLY WAIVE AND RELEASE, INDEMNIFY AND HOLD HARMLESS MCPilates, its directors, officers, agents, contractors, affiliates, managers, subsidiaries, parent companies, employees, volunteers, and their successors, assigns and insurers (collectively, the “Released Parties”) from and against any and all claims, actions, causes of action, liabilities, suits, expenses (including reasonable attorneys’ fees) which are related to, arise out of, or are in any way connected with my participation in any of the above-described Activities including, but not limited to, NEGLIGENCE of any kind or nature, whether foreseen or unforeseen, arising directly or indirectly out of any damage, loss, injury, paralysis, or death to me or my property as a result of my engaging in any of the Activities or the use of the services or equipment of MCPilates, whether such damage, loss, injury, paralysis, or death results from negligence of the Released Parties or from some other cause. I, for myself, my heirs, successors, executors, and subrogees, further agree not to sue the Released Parties as a result of any injury, paralysis, or death suffered in connection with my use and participation in any of the Activities. Any and all MCPilates classes can be filmed live and retained for future content and sale. If you are pregnant, or think you could be pregnant, you should seek advice from your medical provider to confirm your ability to safely participate in the activities. MCPilates reserves the right to request a letter from your medical provider releasing you to participate in the activities. The use of drugs, medication or alcohol may increase the chances of an adverse physical or medical complication from the activities. Please consult your physician if your are in doubt regarding your ability for participate in any of the activities for health reasons. I have carefully read, clearly understand, and voluntarily sign this waiver and release agreement. I also agree that clicking agree below will act as my virtual signature and be legally binding. I have read and agree to the terms above Thank you! Your answers will help to bring you the best workout possible. Schedule a group class or purchase a package today!To schedule private or duet sessions please call or email for availability.Please complete the Client Intake form before registering for your first class.
