register

Please complete the form below to join our classes

Please indicate your preferred day and or time for a class

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of birth

Phone number

Occupation

Emergency Contact

Please include names and phone numbers

Have you done Pilates before?

Please give details of any experience you have

Sport/hobbies?

What are your aims/goals for attending Pilates?

How much exercise do you do on a regular basis, and what are these activities?

Are you on any medication that may affect you during exercise? (if yes, please give details)

Have you any illnesses or disabilities? (if yes please give details)

Has your doctor ever said that you have any sort of heart trouble or defect? (if so please give details)

Do you have high or low blood pressure? (if so please give details)

Please give details of any major or minor surgery in the last 10 years?

Please give details if you suffer from asthma, diabetes, or epilepsy?

Have you ever been told you have arthritic joints, osteopenia, osteoporosis or any other bone or joint problem? (if so please give details)

Please detail any movements / exercises that cause you pain?

Are you pregnant or have you been pregnant in the last six months?

Please list any health problems that you suffer not already mentioned, that may affect your ability to exercise. if you have answered yes to any of the questions 1-10, we advise that you consult with your medical practitioner before you start pilates.

Before you submit this form:

I confirm that I have read and understood the Important Information stated below, and the information I have given is correct. I agree that I am participating of my own free will.

NOTE: Please read the information below before submitting this form.

IMPORTANT INFORMATION

Please advise the teacher, before commencing any exercise, if your health or your ability to perform the particular exercise changes. Exercise is not a substitution for medical counselling or treatment. If you have any doubts about suitability of the exercises, you should refer to a medical practitioner.

The teacher cannot accept any liability for personal injury related to participation in a session, if:

Your doctor has, on health grounds, advised you against such exercise
You fail to observe instructions on safety and technique
Such injury is caused by the negligence of another participant in the session

Exercise should be performed at a pace that is comfortable to you. PAIN is the body’s warning system and should not be ignored. Please inform the teacher immediately if you feel any discomfort during any session. Please also inform the teacher if you felt any discomfort resulting from a previous session. Whilst every effort is made to keep each session safe and effective there is a risk of injury, as with any programme of activity.

I understand that Pilates exercises involves hands-on correction and I hereby consent for the teacher to work in this way.

By submitting this form, you agree that you are participating of your own free will.

At any time, please feel free to discuss any questions you may have about your Pilates sessions.

DATA INFORMATION

I confirm that the Pilates Room and my teacher may use the contents of this form, and any other information I may later provide, for teaching purposes, and that this information:

Will be used in confidence and stored securely.  
Will not, in any circumstances, be shared with a third party without my written consent, unless that party is another Pilates teacher who will teach me.  
May be retained by the Pilates Room and my teacher for a period of time such as complies with professional, legal and insurance requirements that they must fulfil.
 I confirm agreement for the Pilates Room and my teacher to contact me with information on classes and other Pilates-related activities, and understand that I have the right to withdraw this ‘consent to be contacted’ at any time.

register

Please complete the form below to join our classes

IMPORTANT INFORMATION

The Pilates Room Surrey, Dorking Wellbeing Centre,
173 High Street, Dorking, Surrey

Email: info@thepilatesroomsurrey.co.uk Call us on: 07733 419411

register

Please complete the form below to join our classes

IMPORTANT INFORMATION

The Pilates Room Surrey, Dorking Wellbeing Centre, 173 High Street, Dorking, Surrey

Email: info@thepilatesroomsurrey.co.uk Call us on: 07733 419411

The Pilates Room Surrey, Dorking Wellbeing Centre,
173 High Street, Dorking, Surrey