Anchor to Life Pilates Intake Form

Thank you for joining Anchor to Life Pilates. Please complete the following intake form as soon as possible and must be completed before your first session.

I look forward to seeing you soon.

~Amanda

First name

Last name

Phone

Age

Birthday

Month

Day

Year

I voluntarily desire to participate in Pilates exercise training classes conducted by Anchor Pilates, LLC located at 8065 Willow Tree Way Alpharetta, GA 30005.

Yes

I assume full responsibility while voluntarily participating in any training class at my sole risk and shall abide by any and all rules and regulations for use of the facility which may be promulgated from time to time by its owner or Anchor Pilates, LLC.

I understand the rules and regulations.

I am aware that there exists the possibility of certain conditions occurring during or following training and/or exercise. These conditions include, but are not limited to: mild or light headedness, fainting, abnormalities of blood pressure or heart rate, ineffective heart function and in rare instances, heart attack and stroke. The reaction of the cardiovascular system to such activity cannot be predicted with complete accuracy.

For the Above Statement I:

I understand and recognize the above statement.

It is strongly recommended that I receive medical clearance from my private physician prior to starting this or any exercise training program. This program can be designed for persons with known heart disease or those with disorders which require medical supervision however, those persons should have a direct physician referral. Anchor Pilates, LLC reserves the right to deny services to those without their physicians’ written consent/referral.

For the Above Statement I:

I understand that Anchor to Life has right of refusal.

I expressly agree that I have been informed that the program involves possible risks and all exercises shall be undertaken at my sole risk and that neither Anchor Pilates, LLC, nor the Facility, nor the Officers, shall be liable to me or any other person, for any claims, demands, injuries, damages, actions or causes of action, whatsoever, to my person or property arising out of or connected to services and/or exercises having direct relation to this facility. I do hereby release and discharge Anchor Pilates, LLC and the Facility thereof from all claims, demands, injuries, damages, actions, or causes of action and from all acts of active or passive negligence on the part of Anchor Pilates, LLC or the facility, their officers, directors, agents or employees.

For the Above Statement I:

I understand the risk.

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