NEW CLIENT INTAKE FORM
Welcome to Line5 Studios.
To better serve your health and fitness needs, we ask that you please take a few minutes to complete this form.
If you were referred to us, whom can we thank?
What specific fitness or health goals do you hope to achieve through the Pilates?
List all previous and current activities/sports.
Describe your present physical condition.
Describe your physical history, listing injuries, ailments, illnesses, surgeries, pregnancies, and any other significant medical treatments.
Check all body parts that are involved. Also, please note anything else we should be aware of.
Physical Activity Readiness
|PAR-Q & YOU
( A Questionnaire for People Aged 15 to 69 )
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: select YES or NO.
|YES to one or more questions
Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which questions you answered YES.
• You may be able to do any activity you want — as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice.
• Find out which community programs are safe and helpful for you.
|NO to all questions
If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:
• start becoming much more physically active – begin slowly and build up gradually. This is the safest and easiest way to go.
• take part in a fitness appraisal – this is an excellent way to determine your basic fitness so that you can plan the best way for you to live actively. It is also highly recommended that you have your blood pressure evaluated. If your reading is over 144/94, talk with your doctor before you start becoming much more physically active.
DELAY BECOMING MUCH MORE ACTIVE:
• if you are not feeling well because of a temporary illness such as a cold or a fever – wait until you feel better; or
• if you are or may be pregnant – talk to your doctor before you start becoming more active.
PLEASE NOTE: If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan.
Informed Use of the PAR-Q: The Canadian Society for Exercise Physiology, Health Canada, and their agents assume no liability for persons who undertake physical activity, and if in doubt after completing this questionnaire, consult your doctor prior to physical activity.
|No changes permitted. You are encouraged to photocopy the PAR-Q but only if you use the entire form.
NOTE: If the PAR-Q is being given to a person before he or she participates in a physical activity program or a fitness appraisal, this section may be used for legal or administrative purposes.
"I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction."
Signature of Client
|Note: This physical activity clearance is valid for a maximum of 12 months from the date it is completed and becomes invalid if your condition changes so that you would answer YES to any of the seven questions.
||© Canadian Society for Exercise Physiology www.csep.ca/forms
RELEASE OF LIABILITY, WAIVER OF CLAIMS AND ASSUMPTION OF RISKS AGREEMENT (“Agreement”)
PLEASE READ THIS AGREEMENT CAREFULLY. BY SIGNING THIS AGREEMENT YOU WILL WAIVE CERTAIN LEGAL RIGHTS, INCLUDING THE RIGHT TO SUE OR CLAIM COMPENSATION FOLLOWING AN ACCIDENT.
To: Purpleline Lifestyle Concepts DBA Line 5 Studios and their directors, officers, employees, agents, independent contractors, supplies, successors, assigns and representatives (“Releasees”).
Definition: In this Agreement, the term “Wellness Consulting and Activities” shall include all activities, classes, instruction and services provided, arranged, organized, conducted, or authorized directly or indirectly by or on behalf of any one or more of the Releasees and shall further include, but is not limited to: pilates individual sessions and or classes, use of any equipment provided by one or more of the Releasees (“Equipment”) and any other workshops, classes, instruction and services in any way connected therewith.
PAR,Q and Medical Clearance
A. I certify that my responses on the PARWQ form are true and complete to the best of my knowledge.
B. I acknowledge that medical clearance is strongly recommended if I have answered “yes” to any of the questions on the PARWQ form.
C. I acknowledge that I have answered “yes” to one or more questions on the PARWQ form and I have been advised by the Company to seek medical clearance. I am aware of my limitations and have decided to participate in Wellness Activities without seeking medical advice. I am aware that this may place me at greater risk of injury and assume any additional risk.
INITIAL: (if applicable)
Assumption of Risks
I am aware that participating in Wellness Consulting and Activities involves risks, dangers and hazards that include, but are not limited to: mechanical failure of any Equipment; improperly adjusted or maintained Equipment; negligent design or manufacture of Equipment; health risks including, but not limited to, overexertion, dehydration, fatigue, heart attack, stroke, strains/sprains, broken bones, shin splints, joint injuries; and NEGLIGENCE AND GROSS NEGLIGENCE ON THE PART OF THE RELEASEES, INCLUDING FAILURE ON THE PART OF THE RELEASEES TO TAKE REASONABLE STEPS TO PROTECT OR SAFEGUARD ME FROM THE RISKS, DANGERS, AND HAZARDS (a) OF PARTICIPATING IN WELLNESS ACTIVITIES REFERRED TO ABOVE AND (b) ASSOCIATED WITH THE USE OF, OR FAILURE TO MAINTAIN THE EQUIPMENT. I FREELY ACCEPT AND FULLY ASSUME ALL SUCH RISKS, DANGERS AND HAZARDS AND THE POSSIBILITY OF PERSONAL INJURY, DEATH, PROPERTY DAMAGE OR LOSS RESULTING THEREFROM.
Release of Liability, Waiver of Claims and Indemnity
In consideration of the Releasees agreeing to my participation in Wellness Consulting and Activities and permitting my use of their services, Equipment and facilities, and for other good and valuable consideration, the receipt and sufficiency of which is acknowledged, I hereby agree as follows:
1. TO WAIVE ANY AND ALL CLAIMS that I have or may in the future have against the Releasees AND TO RELEASE THE RELEASEES from any and all liability for any loss, damage, expense or injury, including death, that I may suffer or that my next of kin may suffer, as a result of my participation in Wellness Consulting and Activities or use of the Equipment, DUE TO ANY CAUSE WHATSOEVER, INCLUDING NEGLIGENCE AND GROSS NEGLIGENCE, BREACH OF CONTRACT, OR BREACH OF ANY STATUTORY OR OTHER DUTY OF CARE, INCLUDING ANY DUTY OF CARE OWED UNDER THE OCCUPIERS LIABILITY ACT R.S.B.C. 1996 C.337 ON THE PART OF THE RELEASEES, AND FURTHER INCLUDING THE FAILURE ON THE PART OF THE RELEASEES TO TAKE REASONABLE STEPS TO SAFEGUARD OR PROTECT ME FROM THE RISKS, DANGERS AND HAZARDS OF PARTICIPATING IN THE WELLNESS ACTIVITIES REFERRED TO ABOVE;
- TO HOLD HARMLESS AND INDEMNIFY THE RELEASEES from any and all liability for any property damage, loss or personal injury to any third party resulting from my participation in Wellness Consulting and Activities and use of the Equipment and for all costs incurred by the Releasees in relation to the enforcement of the Agreement;
- This Agreement shall be effective and binding upon my heirs, next of kin, executors, administrators, successors, assigns and representatives in the event of my death or incapacity;
- This Agreement and any rights, duties and obligations as between the parties to this Agreement shall be governed by and interpreted solely in accordance with the laws of the Province of British Columbia and no other jurisdiction; and
- Any litigation involving the parties to this Agreement shall be brought solely within the Province of British Columbia and shall be within the exclusive jurisdiction of the Courts of the Province of British Columbia.
In entering into this Agreement I am not relying on any oral or written representations or statements made by the Releasees with respect to the safety of participating in Wellness Consulting and Activities, other than what is set forth in this Agreement. I confirm that I have read and understood the Agreement and that I have had reasonable opportunity to obtain legal advice prior to signing it> and I am aware that by signing this Agreement I am waiving certain legal rights which I or my heirs, next of kin, executors, administrators, assigns and representatives may have against the Releasees.
Thank you form completing our Client intake form. Please make sure to familiarize yourself with Line5 Studio Policies and Etiquette prior to your first session. We will strictly enforce the policies to maintain the highest level of service and instruction.
The Line5 Team