Pilates Waiver

Waiver and Questionnaire

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First name

Last name

Email address

Phone number

Birthday

Emergency Contact Name

Emergency Contact Phone

Medical Background

Please select all that apply

Heart disease or high blood pressureDiabetes or thyroid disorderOsteoporosis or osteopeniaBack or joint painRecent surgery or injuryPregnancy or postpartum (within 6 months)Balance or coordination problemsNeck or shoulder painDizziness or vertigo

Any conditions not mentioned?

Current Medications

List any medications that may affect exercise tolerance:

Current Activity Level

SedentaryLightly ActiveModerately ActiveVery Active

Fitness Goals

StrengthFlexibilityPostureStress ReliefWeight ControlRehabilitation

Other goals not mentioned above?

Agreement to Waiver

Cary Endocrine Wellness Studio

6750 Tryon Rd. Suite 101, Cary, NC 27518

919-650-6345

studio@caryendocrine.com

1. Acknowledgment of Risks

I understand that participating in Pilates and related fitness activities involves physical exertion that may include stretching, resistance exercises, balance training, and the use of specialized equipment. I acknowledge that these activities carry potential risks, including but not limited to muscle strain, sprains, dizziness, falls, or other injuries. I voluntarily participate in these activities and accept all inherent risks associated with them.

2. Health Disclosure

I certify that I am physically capable of participating in Pilates and have disclosed any relevant medical conditions to my instructor, including (but not limited to): - Heart, lung, or circulatory conditions - Musculoskeletal injuries - Diabetes, thyroid, or endocrine disorders - Pregnancy or postpartum status - Any condition for which physical exertion should be limited If I am under a physician’s care, I have obtained medical clearance to participate in Pilates classes.

3. Release of Liability

In consideration of being permitted to participate in classes, sessions, or workshops at Cary Endocrine Wellness Studio, I hereby release, waive, and discharge Cary Endocrine & Diabetes Center, Cary Endocrine Wellness Studio, its owners, instructors, employees, and affiliates from any and all claims or liabilities arising from my participation, whether caused by negligence or otherwise.

4. Assumption of Responsibility

I understand that it is my responsibility to: - Follow all instructor directions and use equipment safely. - Immediately inform the instructor of any discomfort, pain, or unusual symptoms. - Stop exercising and seek medical attention if necessary.

5. COVID-19 and Infectious Disease Acknowledgment

I acknowledge that despite precautions, participation may expose me to communicable diseases, including COVID-19. I voluntarily assume this risk and agree to comply with all studio health and sanitation guidelines.

6. Agreement and Signature

I have read and fully understand this waiver and release. I voluntarily agree to its terms and sign it freely.

Type your full legal name as your electronic signature