New Client Form

Personal Details

Name:

Date of Birth:

 Address:

Telephone 

(Home):                                      (Mobile):

Email:

Profession:

Recommended by: 

Height:

Weight:

 Medical Information

Do you use, suffer from, or have you suffered from any of the following:

Smoking:

Epilepsy:

Diabetes:

High/low blood pressure:

Headaches:

Asthma/breathing:

Heart Problems:

Neck Problems:

Joint Problems:

Back Problems:

Describe fully if you suffer, or have you suffered from any of the neck, joint or back problems: 

Do you take any prescribed medication? If yes, please give details: 

Any past major operations:

List any other physical fitness or sport programmes you are following at the present time:

If over 45 years of age:

Have you had a recent medical?: Y/N

Were the results satisfactory?:

Have you had a recent bone density scan?: Y/N

If yes, what were the results?

Does your doctor recommend physical exercise?:Y/N

Any Doctor advice on physical exercise?

(If you have not had a bone density scan, we highly recommend having one)

Before taking part in any class, please report any new injuries or ailments to the instructor and ensure you are sufficiently hydrated and in good health to take part in physical activity.

 TERMS AND CONDITIONS

We require a minimum of 24-hour’s notice of any cancellations.  Classes cancelled within 24-hours of the scheduled class time will be charged at the full rate.  With sufficient notice, we can move a session without charge within the same week, subject to availability, however this session cannot then be cancelled, or you will be charged. All pre-paid blocks of sessions are non-refundable and are valid for 6 months from the last class attended, unless you inform us that you are going to be away for a longer period of time and wish to hold your classes.

 PRIVACY NOTICE & PERSONAL DATA

The personal data on the New Client Form is collected by JC Fenner Pilates to provide tailored tuition services to you.  We do not send out general client mailings and will only use your contact details in matters of legitimate interest – e.g. unexpected studio closure, class re-arrangment etc.  No data is ever shared with third parties.  Your personal data will be stored securely while you are a client of JC Fenner Pilates.  If you wish to examine the data held, or require us to destroy it, please let us know.  Your signature confirms your consent for JC Fenner Pilates to use your data as specified above and that the information given by you on the New Client Form is complete and accurate.

IMPORTANT GUIDELINES FOR ON-LINE CLASSES

It is the responsibility of the participant: (a) to ensure there is sufficient space to perform the exercises safely and move freely without obstacles or obstructions, free from furniture, equipment and other hazards that may increase the risk of slips, trips or falls (b) that any equipment they use is safe and in a suitable condition for the activity being performed, (c) there are no distractions throughout the duration of the session and (d) there is sufficient heating, lighting, ventilation in the room.

DISCLAIMER FOR ON-LINE CLASSES

As with all fitness and exercise programmes, when participating in on-line classes or using exercise videos please ensure you are able to take part safely. To reduce the risk of and avoid injury, you should check with your doctor before beginning any fitness programme. By performing any fitness exercises without supervision, you are performing them at your own risk.  JC Fenner Pilates will not be responsible or liable for any injury or harm you sustain as a result of this online fitness programme, online fitness video or information shared on our website, via email, videos, text or other communication. 

Signature:

Date: