Health & Participation Form

01

Your details

Fields marked * are required.

First name *

Last name *

Email address *

Mobile number *

Date of birth *

02

Emergency contact

Someone we may contact if you become unwell or injured.

Contact name *

Relationship to you *

Contact number *

03

Health screening

Please answer every question honestly.

Answering “Yes” does not automatically mean that you cannot join a class. We may contact you to discuss suitable adjustments or ask you to seek advice from a qualified healthcare professional first.

1. Has a doctor or another qualified healthcare professional advised you to exercise only under medical supervision? *

Yes No

2. Do you experience chest pain during physical activity, or have you recently experienced unexplained chest pain while resting? *

Yes No

3. During the last 12 months, have you lost consciousness or lost your balance because of dizziness? *

Yes No

4. Do you have a bone, joint, muscle, back or pelvic-floor problem that could be made worse by exercise? *

Yes No

5. Are you taking prescribed medication, or managing a medical condition, that could affect your ability to exercise safely? *

Yes No

6. Are you currently pregnant, have you recently given birth, or have you been advised that you need pregnancy-related exercise adaptations? *

Yes No

7. Have you had surgery, a significant injury or a hospital admission during the last 12 months that could affect your participation? *

Yes No

8. Is there any other reason you may need medical advice or an adaptation before taking part in a Pilates class? *

Yes No

If you answered “Yes”, please provide brief relevant details

Include any movements you have been advised to avoid or adjustments you may need. Please do not provide a full medical history.

04

Participation agreement

Please read each statement before confirming.

I confirm that the information I have provided is accurate and complete to the best of my knowledge. * I understand that physical activity carries inherent risks. I agree to follow the instructor’s guidance, work within my own ability and stop immediately if I feel pain, dizziness, unusual breathlessness or become unwell. * I will tell the instructor about relevant changes to my health. If I have answered “Yes” to a screening question, I understand that I may be asked to obtain advice from a qualified healthcare professional before participating. * I explicitly consent to Blush Bodies using the health information in this form for the purpose of assessing and supporting my safe participation. I understand that I can withdraw this consent by contacting Blush Bodies, although this will not affect processing that has already taken place. See the Privacy Policy . *

Type your full name as your signature *

Date completed *