Highly qualified instructor | classes for all bodies, ages, abilities - Milton & Mollymook. Dynamic Pilates for strength | stability | flexibility | injury prevention | intuitive movement. Join us!Client Registration

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Client Registration
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CLIENT REGISTRATION

Please read the form and the complete the details and signature below prior to your first class. Any questions please contact us.

Registration Form

Details and Signature

First Name*

Last Name

Email*

Contact Number*

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Date of Birth*

Home address*

Address Line 1

Address Line 2

Suburb

State

Postcode

Emergency Contact Name and Relationship*

Emergency Contact Phone*

Health Declaration - please select those that are applicable

Heart condition, high or low blood pressure, or circulation problem

Currently pregnant, or given birth in the last 12 months

Surgery in the last 12 months, or a current injury

Back, neck or joint condition, or ongoing pain

Osteoporosis, osteopenia or a previous fracture

Dizziness, fainting, balance problems or epilepsy

Diabetes, asthma or another condition that affects exercise

Blood-clotting disorder, or taking blood-thinning medication

Allergies (for example latex, massage oils or metals)

Implanted medical device (for example a pacemaker)

Any other condition, medication or concern we should know about

None applicable

Health Details

If you selected any of the above health conditions or if there is anything you think we should know please add details

I have have read, understand and accept all relevant Sections in the Registration Form

Yes

Section 4 Massage is accepted

Section 4 Dry Needling is accepted

Signature of named Client*

✗

By signing above I confirm that I have read and understood this form and the registration document (including the warning in Section 3), I have had the chance to ask questions, the information I have given is true, and I agree to Sections 1 to 3 and 5, and to Section 4 if I am receiving those treatments as indicated above.

Name and Relationship to Client

For Parents/Guardians of Clients U18

Parent/Guardian Signature

✗

By signing above I confirm that I have read and understood this form and the registration document (including the warning in Section 3), I have had the chance to ask questions, the information we have given is true, and I agree to Sections 1 to 3 and 5, and to Section 4 if the client is receiving those treatments as indicated above.

“Every moment of our life can be the beginning of great things.”

– Joseph Pilates.

CONTACT FOCUS PILATES AND MASSAGE

Email:

focuspilatesandmassage@gmail.com