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Pilates Mat or Reformer Waiver
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Home
About Diana Bufalini
Private Sessions
Pricing
Pilates Mat or Reformer Waiver
Cancellation Policy
Schedule a Session
Videos
Log & Blog
Please complete the below waiver before attending your first session with Diana Bufalini Pilates. Thank you.
Name
*
First Name
Last Name
Email Address
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
Please list any injuries, health conditions or recent accidents
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
Please list any injuries, health conditions or recent accidents:
Are you currently under any medical care or supervision or taking any medication?
*
Yes
No
If the answer to any part of the above is “yes” please describe your medical situation and any medications you are currently taking.
Have you been advised by your physician not to engage in strenuous physical activity?
Do you exercise?
*
Yes
No
If you answered "YES" above, what type of activity?
Height in Feet and Inches
Ex: 5' 5"
Do you have any other issues or concerns that you would like to discuss with your instructor?
Please read below, accept the terms and sign and date the document
I agree to take full responsibility for not exceeding my physical limits in the study and practice of DIANA BUFALINI PILATES, LLC and for any resulting injury or discomfort I might experience from the study and practice of DIANA BUFALINI PILATES, LLC. I recognize that DIANA BUFALINI PILATES, LLC requires physical exertion, which may be strenuous at times and I am aware of the risks and hazards involved in physical activity of this nature It is my responsibility to consult with a physician prior to and regarding my participation in DIANA BUFALINI PILATES, LLC. I represent that I have not been advised by any physician or physical therapist not to participate in strenuous physical activity. I waive any claim that I might have at any time for any injury, damage to property, loss of income, monetary damages or the like against DIANA BUFALINI PILATES, LLC, any related company and any agent ,servant or employee of DIANA BUFALINI PILATES, LLC. I do forever release DIANA BUFALINI PILATES, LLC, its agents, servants and employees, jointly and severally, , from all liability of any kind whatsoever, whether past, present, or future for any injury and damages of any kind which may occur as a result of my participation in DIANA BUFALINI PILATES, LLC. I agree to hold harmless and indemnify, including reasonable legal fees, DIANA BUFALINI PILATES, LLC, its agents, servants and employees of for all actions, claims, or other legal or administrative proceedings that arise from any misrepresentations contained in this document and /or resulting from my participation in this service. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.
*
Check here to confirm
Name
*
First Name
Last Name
Date Signed
*
MM
DD
YYYY
Thank you! I look forward to seeing you soon.