I would like to book a place on the following session with Wendy Broad:
--- AT-Pilates starting Tuesday 31 Jan at 7pm at Kelsall Hill Your name:
Telephone:
Mobile:
Email:
Date of Birth:
Home Address:
Emergency contact:
GP:
Where did you find out about classes and workshops with Wendy Broad?
Do you have any particular needs that it would be useful for us to know about e.g. restricted mobility (can you safely get down to the floor and lie on your back, front and side?, do you have hearing or visual impairment? Please provide relevant information.
Would you like to join our mailing list? We may send you newsletters, marketing material or promotional info from time to time.Yes No
OCCUPATION AND LIFESTYLE
What is your occupation?
1) Does your occupation or lifestyle require extended periods of sitting?Yes No
2) Do you participate in physical activity such as golf, swimming, walking?Yes No
3) Have you done any Pilates before?Yes No
4) Have you experienced Alexander Technique before?Yes No
HEALTH SCREENING QUESTIONNAIRE
If you are between ages 15 and 69, the health screening questionnaire will tell you if you should check with a doctor before you significantly change your physical activity patterns. If you are over 69 years of age and are not used to being very active, please check with your doctor first. Please answer all questions below:
1) Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?Yes No
2) Do you feel pain in your chest when you do physical activity?Yes No
3) In the past month, have you had a chest pain when you were not doing physical activity?Yes No
4) Do you lose balance because of dizziness or do you ever lose consciousness?Yes No
5) Do you have a bone or joint problem (for example arthritis, hypermobility, osteoporosis, slipped disc, joint replacement)Yes No
6) Do you suffer from lower back pain i.e chronic pain or numbness?Yes No
7) Is your doctor currently prescribing medication for your blood pressure or heart condition?Yes No
8) Are you pregnant or have you been pregnant in the last 6 months?Yes No
9) Do you know of any other reason why you should not take part in physical activity?Yes No
If you answered YES to one or more questions please give details:
IMPORTANT PLEASE READ THIS CAREFULLY
If you have answered YES to any of the above questions, you should consult with your doctor to clarify that it is safe to become physically active at this time. Please mention anything else that I may need to know to keep your session safe both now and in the future. Whilst every effort is made to keep the sessions both safe and effective, there is a risk of injury as with any programme of activity.
Please feel free to discuss any questions or queries you may have regarding your session with Wendy. On rare occasions there may be a stand in teacher.
INFORMED CONSENT/ TERMS AND CONDITIONS
1) I hereby state that I have read, understood and accurately completed this pre-exercise health screening questionnaire.
2) Whilst every effort is made to keep the session safe and enjoyable, I confirm that I am participating of my own free will and I acknowledge that as with any exercise or movement programme there is a risk of injury and following the pandemic there is still a risk of catching Covid-19. I acknowledge that I am taking part at my own risk. I acknowledge that Wendy Broad does not accept responsibility for any individual or group of individuals, who may be participating in Wendy's Pilates classes, Alexander Technique sessions, AT-Pilates sessions or Mind-body-awareness workshops.
3) Any questions that I had were answered to my full satisfaction.
4) I agree to follow the guidelines and instructions throughout the sessions and work within my safe limits. For Pilates and AT-Pilates clients, I acknowledge that Pilates and AT-Pilates exercises are progressive and I can choose to exercise at a lower level or to rest at any time. I agree to use Pilates equipment according to the manufacturer's guidelines.
5) During sessions if I am in pain, I agree to stop immediately and inform the teacher. I will ask for an alternative exercise or movement pattern at any time if necessary.
6) If I answered NO to all questions in the Health Screening Questionnaire, I acknowledge that I may participate in physical activity without consulting my doctor.
7) If I answered YES to any questions in the Health Screening Questionnaire, I have sought medical advice and my doctor has agreed that I may exercise. Written permission is not required.
8) I agree to inform the teacher if my medical health status changes or any new health conditions arise.
9) By taking part in this session I agree to the above terms and conditions.
Participant's Signature (please write your name here):
Date:
Data Protection Policy and Privacy Policy
Your data will be handled according to my Data Protection and Privacy Policy.
The health information is collected for my insurance purposes and to enable us to respond to your needs and assess for class suitability. Your personal contact details may be used by us to contact you about events and offers, if you give us permission to do so. Your contact details are not shared with third parties. A paper copy of your information is held in a locked cabinet for a period of 5 years as a condition of my insurance policy. After this time your information will be destroyed.
