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                       Contact | Enrollment Form

Enrollment Form

Please print this page, fill out the form and bring it with you to your first class.

ENROLLMENT FORM

First and last name ________________________________________________________
Address _________________________________________________________________
Email address Home _______________________________________
Work (optional) __________________________________________
Telephone number Home ___________________
Work (optional) __________________________
Mobile (optional) _________________________

Profession/type of work ______________________
Date of birth ____________________

Class(es) you are interested in:

Pilates Mat Classes
Dance Fundamentals
Privates

Level: Beginner Intermediate Advanced
Number of classes per week - One or Two

Which location(s)_________________________________________________________

Active in other sports _____________________________________________________

Illnesses ________________________________________________________________
Current _________________________________________________________________
Past ___________________________________________________________________
Stabilized? ___________When? _______________

Injuries _________________________________________________________________
Current _________________________________________________________________
Past ___________________________________________________________________
Stabilized? ___________________When? ____________________

Any physical limitations advised by healthcare professionals? yes no
If so, what are the limitations, advised by whom?

How did you hear of PilatesforeveryBody _____________________________________

_______________________________________________________________________

Your signature on this form confirms that this information sheet has been truthfully completed by you. You agree that you participate in the lessons at your own risk and that Loretta Simon Helms and other instructors and lessors of premises where the lessons are held are in no event liable for any damage or injury you may incur.
Privacy Protection. This information will be used to identify you to other instructors of Pilates and to advise you on developments on Pilates. It will not be given to any third parties.

Signature________________________________

 

 

 

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