new client
intake form

Name

First Name

Last Name

Primary Phone

(###)

###

####

Alternate Phone

Optional

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Person

First Name

Last Name

Phone Number of Emergency Contact Person

(###)

###

####

Date of Birth

MM

DD

YYYY

Are you:

Right-handed

Left-handed

Ambidextrous

Do you smoke?

Yes

No

Do you have high blood pressure?

Yes

No

Do you have a history of heart problems?

Yes

No

Do you have asthma?

Yes

No

Do you experience vertigo or dizziness?

Yes

No

Do you have osteoporosis or osteopenia?

Yes

No

Do you experience blurred vision?

Yes

No

Do you have diabetes?

Yes

No

Do you have a hernia?

Yes

No

Do you have diastasis recti?

Yes

No

Are you a diet soda drinker?

Yes

No

The above-stated health information is true and accurate to the best of my knowledge.

I have volunteered to participate in a program of progressive physical activity which may include but is not limited to: weight and/or resistance training, cardiovascular training, flexibility, and balance (Program) under the direction of Brenda Andreasen and Engage Penguin Studios/b:pilates (Studio). To the best of my knowledge, I am in good physical condition and I have no disease, physical limitations, health concerns, or injury other than as disclosed, that would be aggravated or would be the cause of any injury sustained, before, during or as a result of my participation in activities related either directly and/or indirectly to this Program. I recognize that exercise might be difficult and strenuous and that there could be dangers inherent in exercise for some individuals. I acknowledge that the possibility of certain unusual physical changes during exercise does exist. I recognize that an examination by a physician should be obtained prior to involvement in any exercise program. If I have chosen not to obtain a physician’s permission prior to participation, I hereby agree that I am doing so at my own risk and I assume the risks associated with any and all activities and/or exercises in which I participate. I agree to comply with all Studio policies and rules, signage, and instructions including those related to COVID-19 while participating in the Programs at the Studio. I understand that the Studio is open for use by other individuals and as such, I acknowledge that there is a higher risk of exposure to COVID-19. I am participating in the Studio's Programs voluntarily and with the full understanding of any risks and I release, waive, and discharge Brenda Andreasen and Engage Penguin Studios/b:pilates from any and all liability, claims, and causes of action directly or indirectly arising out of or related to any loss, or injury that may be sustained by me, including any claims related to COVID-19 whether caused by the Studio, any third-party using the Studio, or otherwise, while partcipating in any activity while in, on, or around the Studio and/or while using any of the Studio’s facilities, tools, equipment, or materials. I ACKNOWLEDGE THAT I HAVE THOROUGHLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A RELEASE OF LIABILITY.

By signing this form and waiver, I agree to the above terms and conditions.

I acknowledge that my name below represents my signature.

First Name

Last Name

Today's Date

MM

DD

YYYY

Name of parent/guardian if participant is a minor:

First Name

Last Name