Print this form and complete for your enrolment

Name:.......................................................................................................................................................................................

Address:...................................................................................................................................................................................

.......................................................................................................................................................Postcode:..........................

Telephone Numbers: ...........................................................................................................................................................

Contact of relative in case of emergency:..........................................................................................................................

Email Address:......................................................................................................................................................................

Date of Birth:..........................................................................................................................................................................

Occupation:...........................................................................................................................................................................

Sports/Hobbies:...................................................................................................................................................................

Preferred Class Day & Time:...........................................................................................................................................

How did you find out about Pilates Northside? Please tick...................

Does your work/sport involve any of the following ? Please circle::

1) Has your doctor ever said that you have any sort of heart trouble or defect?......................................Yes / No

2) Have you ever been told that you have arthritic joints or any bone or joint problem that may be made worse by exercise?.........................................................................................................................................................Yes / No

3) Are you pregnant, or have you had a baby in the last 6 months?..........................................................Yes / No

4) Have you had any operations or injuries in the last year?......................................................................Yes / No

5) Is there any other good reason not yet mentioned that should stop you performing physical exercise?

...............................................................................................................................................................................Yes / No

6) Do you suffer from backache?.....................................................................................................................Yes / No
If so, do you know why?....................................................................................................................................................

7) Is your blood pressure: ..............................................................................................................High / Low / Normal

8) Have you ever been given any remedial exercises?..................................................................................Yes / No

If so, can you briefly describe them?.................................................................................................................................

9) Are there any movements that cause you pain? (eg, raising your arms, bending forward or to the side etc)............................................................................................................................................................................Yes / No

10) Do you wish to strengthen a particular area?..........................................................................................................

Any other comments:...........................................................................................................................................................
Note: If you have answered ‘yes’ to any of the above, please give relevant details in confidence.

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Please advise the instructor before commencing a class if for any reason your ability to exercise has changed. It is inadvisable to do Pilates between weeks 8 to 14 of pregnancy, unless by special arrangement with the Instructor. It is also wise to wait six weeks after the birth before resuming exercise.

Pilates exercises are very safe but, as with all forms of physical exercise, it is prudent to consult your doctor before starting classes. The classes are not a substitute for medical counselling or treatment. If you have any doubts about the suitability of the exercises, you should refer back to your medical practitioner. The Instructor can accept no liability for personal injury related to participation in a class if:
(a) your doctor has, on health grounds, advised you against such exercise.
(b) you fail to observe instructions on safety or technique
(c) such injury is caused by the negligence of another participant in the class, or a third party, such as the owner of the venue.

Signed: ............................................................

Date:....................................

Thank you. Please return this form to:
Pilates Northside
PO Box 2035
Strathpine Qld 4500

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Pilates Northside is committed to the protection of your personal information in accordance with the requirements of privacy legislation. It is a policy of Pilates Northside that any personal information will not be disclosed to any third party without prior consent.

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