Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Have you been hospitalized in the last 12 months? *

No

Yes

Are you currently suffering from a medical condition, illness, or injury? *

No

Yes

Todays Date *

MM

DD

YYYY

*

I declare that the information I have provided is accurate and complete. I certify that my participation in Pilates and MELT is a potentially hazardous activity. I have been informed of, understand, and am aware that any exercise and/or fitness activities involve a risk of injury, and I am voluntarily participating in these activities with an understanding of the risks involved. I hereby agree to expressly assume and accept any and all risks of injury, regardless of severity. I understand that all information and services provided by Michèle Oppliger and Michèle Oppliger Pilates are of a general nature and are provided for educational purposes only. None of the information or services provided by Michèle Oppliger and Michèle Oppliger Pilates are to be taken as medical or other health advice pertaining to any specific health or medical condition(s) that I have or may have had. The information and services provided by Michèle Oppliger and Michèle Oppliger Pilates are not a diagnosis, treatment plan, or recommendation for any particular course of action regarding my health and are not intended to provide specific medical advice.

I have read the disclaimer.