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Registration
Form
STUDIO 1 Pilates n Movement,
LLC
Student's Name _________________________________________________________________________________
Age _______ Home Phone
_________________________ Work Phone
_______________________ Cell Phone _________________________ Address ________________________________________________ City_______________________ State _________ Zip _______ Email Address ______________________________________ Referral from ____________________________________________ Parents’ Names, if
under age 18 or Emergency Contact
_____________________________________________________________ Health
Information Weight ______ Height ______ Handed ____ Chief Complaint
_______________________________________
________________________________ What Aggravates ___________________________________________________________ What Eases ____________________________________ Current Medical
History ________________________________________
___________________________________ Past Medical History______________________________________________________ _________________________________________________________
Medications_______________________________________ Smoking/Alcohol ________________________________________ Social/Hobbies _______________________________________ Exercise ________________________________________________ Work
_____________________________________________ What is important to
you/Goals
_________________________________________________________________________________ DAY TIME DESCRIPTION FEE ________________________________________________________________________________________________ ________________________________________________________________________________________________ I have read and acknowledge and agree to the policy and fee structures.
Initial ________________ I certify that I/student is in good health and capable of
participating in all activities and classes. Initial ________________ I realize that risk of injury is involved and I hereby release
Wallis M. Mason, STUDIO 1 Pilates n Movement, LLC and its agents and employees from all
liability for personal injury, or property damage. Initial ________________ Parent or Adult
Student's Signature
______________________________________________ Date ________________
(Required) Session Course Fee ________
Administration Fee
$25.00 ** Other
________ Discount/Adjustment ________ Total payment ________ Credit card
info ACCOUNT NUMBER
_______________________________________ CID _________(SEC # ON BACK) EXP ________ circle one VISA
MC DISCOVER
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