Intake Form

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Age

Birthday

Gender

How did you hear about me? :)

If 'Other' Please Specify

Name Of Physician (Optional)

Physician's Phone (Optional)

Your Physical Health & Goals

What Goals Do You With To Achieve Through Pilates?

Have You Done Pilates Before

If 'Yes', Where & For How Long?

List Your Current Exercises and Activities

How well do you feel you understand your body (check all that apply).

I feel lost in my body

I understand the general structures

I remember some anatomy

I understand my anatomy but not so much the function/movement

I deeply understand anatomy/physiology

I'd like to explain more below:

Injuries? Yes/No. If yes, please explain:

Physician ever restrict your physical activity? Explain:

Accidents or Surgeries?

Illnesses or Ailments?

Number of Pregnancies?

Comments or Anything Else Not Listed Above?

Emergency Contact

First Name

Last Name

Phone

(###)

###

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Terms & Agreements :

Liability and Waiver Release

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNIFICATION AGREEMENT In consideration of being permitted to enter upon, participate in and use the facilities, equipment, services in person or online, and activities of or offered by LarissaPilates, and its agents, owners, employees, partners, independent contractors, volunteers, and all other persons acting in any capacity on their behalf (collectively, the “LarissaPilates Parties”), I, on behalf of myself, my guests, children, heirs, executors, administrators, successors and assigns, hereby: Acknowledge, understand and appreciate that entry upon and use of the facilities, equipment, services in person or online and activities of or offered by LarissaPilates entails significant risk, both known and unknown, including, without limitation, physical or emotional injury, paralysis, death, other serious or catastrophic personal injuries and loss or damage to personal property. Expressly agree and promise to accept and assume all of the risks, both known or unknown, existing with my entry upon, participation in and use of the facilities, equipment, services in person or online and activities of or offered by LarissaPilates, whether such risks are caused or alleged to be caused by the negligent acts or omissions of LarissaPilates. I hereby confirm that I am voluntarily entering upon, participating in and using the facilities, equipment, services and activities of or offered by LarissaPilates, and that I am electing to take such voluntary actions in spite of the risks. I acknowledge and agree that I am solely responsible for my safety and responsible entry upon, participation in and use of the facilities, equipment, services in person or online and activities of or offered by LarissaPilates, whether or not supervised by LarissaPilates. Voluntarily release, forever discharge, and agree to indemnify, defend and hold harmless, each of LarissaPilates from any and all claims, demands, causes of action or liability for loss, damage, injuries or death I may suffer or cause another to suffer in connection with my entry upon, participation in or use of the facilities, equipment, services in person or online or activities of or offered by LarissaPilates, whether the same arises out of or results from any act, omission or conduct of any of LarissaPilates, negligent or otherwise. Acknowledge that I have carefully read this Agreement and am aware that it contains a waiver and release of liability and that I am giving up substantial rights, including my right to sue OR HOLD LARISSAPILATES RESPONSIBLE FOR ANY INJURY WHICH I MAY SUFFER. I am signing this Agreement of my own free will and intend for my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. Expressly waive my right to all remedies in court, including any right to a jury trial, and agree to resolve any and all claims, causes of action, disputes and controversies arising out of or relating to my entry upon, participation in or use of the facilities, equipment, services in person or online or activities of or offered by LarissaPilates by final and binding arbitration using the American Arbitration Association’s Commercial Arbitration Rules. This includes, but is not limited to, claims related to fee disputes, personal injury, property damage and any other claim which may be asserted under the law of contract and/or law of tort and/or asserting a public policy or Constitutional claim. The laws of the State of California shall govern the dispute. If any part of this Agreement is held to be invalid, the remainder shall continue in full legal force and effect.

LARISSAPILATES Policies

LARISSAPILATES POLICIES Twenty-four (24) hour notice is required for cancellation from all lessons and classes. If you do not provide twenty-four (24) hour prior notice of cancellation you will be charged for the lesson or class. If you are running more than 15 minutes late please let LarissaPilates know, otherwise the class or lesson will be cancelled and charged. All packages are valid for six months from date of purchase. Packages are non-transferable and non-refundable. After six months, any unused classes shall terminate and expire. Lessons and Classes are 55 minutes in length unless otherwise noted. Students shall notify LarissaPilates of any change in their physical condition prior to each lesson or class. In case of teacher illness or emergency, every effort will be made to avoid cancellation for the class or lesson. LarissaPilates will notify clients of cancellation with as much prior notification as possible. Please have your equipment and camera’s location ready five (5) minutes before your Zoom Virtual class or lesson begins. If you know you’ll have excessive background noise upon entering class, especially if entering the class late, please mute yourself.