Email

Address

Emergency Contact - Full Name & Phone

Injuries/Medical Conditions

Please list any current or prior injuries and/or medical conditions. Be specific as possible with dates and diagnosis.

Current Excercies

Please list type and frequency of your current activity level.

Are you interested in private Pilates sessions, Melt Method sessions, or both?

How did you hear about Heartwood Pilates

What are your short term and long term Pilates goals?

Waiver of Liability

• I will receive information and instruction while participating in the session/class offered by Maureen Delaney at Heartwood Pilates • I recognize that this class will require physical exertion, which may be strenuous and may cause physical injury, and I am fully aware of the risks and hazards involved. • I understand that it is my responsibility to consult with a physician prior to and regarding my participation in this class or any other activity associated with Maureen Delaney at Heartwood Pilates. • I represent and warrant that I am physically fit and have no medical conditions that would prevent my full participation in the session/class. • I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I may incur as a result of participating in the program. • I knowingly, voluntarily and expressly waive any claim that I may have against Maureen Delaney and Heartwood Pilates for injuries or damages that I may sustain as a result of my participation. • Heirs, my legal representatives and I forever release and waive any liabilities against Heartwood Pilates and Maureen Delaney for any injury or death incurred by my voluntary participation in this session/class. By writing in your name and date in the field below you indicate that you have read the above release and waiver of liability and fully understand their contents. You voluntarily agree to the terms and conditions stated above. Full name and date:

New Client Intake & Waiver Form