ELEMENTALFITNESS

CLIENT INTAKE FORM

Before you participate in Pilates or alfresco sessions with Elemental Fitness we need to know a little about you. Please fill out the information below. Your preferences, and any other pertinent information you’d like to share can help create an optimum program for your practice.

Myriam Kane

mfkane@verizon.net

www.elementalfitness.net

703.795.5866

Please read the following AGREEMENT of RELEASE and WAIVER of LIABILITY before signing:

In consideration of and as inducement to you enrolling me as a student of Elemental Fitness LLC I represent and agree as follows:

I am presently in good health. I have been examined by a licensed physician within the last 6 months and found by such physician to be in good physical health and found to be able to fully participate in Pilates and fitness programs.

I fully understand that I am to receive instruction in Pilates and other fitness exercise only and will not hold Elemental Fitness LLC, partners or instructors, to any higher standard of care than applicable.

I hereby release, waive, discharge and covenant not to sue Elemental Fitness LLC, its instructors, agents and employees (herein described as “Releasees”), from all liability to the undersigned, his or her personal representatives, assigns, heirs, and next of kin for any and all loss or damage, and any claims or demands therefore on account to injury to the person or property or resulting in death or injury of the undersigned whether caused by the negligence of the Releasees or otherwise while I am in or upon the premises used by Releasees.

I hereby assume full responsibility for and risk of bodily injury, death or property damage that may be due to the negligence of the Releasees arising out of the necessity of defending any law suit instituted by virtue of injuries, death or property damage, suffered by me, or injuries, death or property damage caused by me.

I further expressly agree that the foregoing release, waiver and indemnity agreement is intended to be as broad and inclusive as is allowed by the laws of the State of Virginia and that, if any portion thereof is held to be invalid, it is agree that the balance shall, not withstanding, continue in full legal force and effect.THis includes sessions taken in person as well was via video and online.

I have read and voluntarily signed this form, and further agree that no oral representations, statements or inducements apart from the foregoing written agreements have been made. This release contains the entire Agreement between parties hereto, and the terms of this release are contractual and not a mere recital. I understand the above pertains to sessions in person or via Zoom.

The tuition paid herewith and such registration fees paid hereafter are non-refundable and non-transferable.

I FURTHER STATE THAT I HAVE READ THE FOREGOING RELEASE, KNOW THE CONTENTS THEREOF, FULLY AGREE WITH IT, UNDERSTAND IT AND ACKNOWLEDGE THAT I AM SIGNING THE SAME AS MY OWN FREE ACT. I HAVE READ AND AGREE TO THE REFUND POLICY BELOW.


 

 

 

 

Class Refund/Cancellation Policy:
All classes/sessions require 24 hour advance notice of cancellation.
Failure to give appropriate notice will result in charges for the full amount of your session.
All sales are final, no refunds.

Your Signature