Pilates / Yoga Form | Welcome to D'Pilates.com : Plano, TX

Please down load and fill out this form Send the PDF to us in an email or print it out and bring them with you.
OR
use our on-line form found below. You must complete and turn in/submit this form before participating in any classes or private sessions at d’Pilates.

dPilates New Client Form

Service Policy

All services are subject to a 24 hour cancellation rule. Any appointment, including group classes, not cancelled before 24 hours of the scheduled time will be charged the full service rate. The studio will not charge due to cancellations for severe weather.

All services must be prepaid to hold your spot. This applies to all services from private lessons to group classes. Spots cannot be held without payment. This includes leaving for vacation or other extended absences. If you would like us to hold your time(s), you must prepay for one weeks lesson.

Discounts for services will only be given in packages. If you would prefer to pay per lesson, a single lesson rate will be applied. There are no refunds on unused packages or services.

All services require prior permission to attend. There are no drop in services.

All services expire three (3) months from the purchase date.

Students are expected to be on time for lessons. All lessons are 55 minutes and start at the scheduled time of the appointment. Lessons will not be extended for tardiness. Students arriving more that 15 minutes late – without calling – will be considered a late cancellation and will be charged the full lesson rate. Anyone showing more than 10 minutes late for a group class – exception solos – will be charged and not allowed to participate. We feel it is unsafe to join a group class after the warm up and it is unfair to slow the progress of the other participants.

There are no refunds on unused services and gift certificates.

Client Name *

Please enter your name here.

Client Address *

Apt, suite, etc.

Country

City

State

Zip code

Please add your full address here.

Client Cell Phone *

Please enter your cell phone number.

Client Work Number *

Please add your work phone number.

Home Phone Number *

Please enter your home phone number if different from your cell number.

Occupation *

Email *

Please enter your email address.

Birthday *

Sex *

Male

Female

Emergency Contact *

Please let us know who we can contact in case of emergency.

Emergency Contact Phone Number *

Please indicate a cell, work or home phone number for your emergency contact.

Emergency Contact Email *

Please indicate your emergency contact\'s most active email.

Relationship *

What is the relationship of your emergency contact and you?

Goals and Objectives *

What are your goals and objectives?

Sports *

What sports do you currently participate in?

Exercise Restrictions *

Yes

Do you have any medical condition that may be affected by exercise?

If Yes please describe: *

(i.e. Pregnancy + Due Date)

Other Factors: *

What other factor(s) may affect your ability to engage in an exercise program?

Health Conditions and Training

Many health conditions affect various aspects of Pilates health development and training. Please complete the following d\’Pilates Health Questionnaire and discuss any pertinent health issues with you trainer.

Overall Health Condition *

Excellent

Good

Fair

Poor

Please rate your overall health condition:

Do you smoke? *

Yes

A little

In process of quiting

Respiratory Problems *

Please describe any respiratory problems you currently suffer from.

Circulatory Problems *

Please describe any circulatory problems you currently suffer from.

Heart Condition *

Please describe any heart problems you currently suffer from.

Previous Surgery *

Please describe any surgeries (including c-sections) that you have had.

Previous or Current Cancer *

Please describe any cancer(s) you have or are suffering from.

Immune System Disorder *

Please describe any immune system disorder that you currently have.

Epilepsy or Seizures *

Please describe any epilepsy or seizures you suffer from.

Back pain *

Please sepcify the type and location of any back pain you suffer from.

Hip pain *

Please specify the type and location of hip pain you suffer from.

Neck pain *

Please specify the type and location of neck pain you suffer from.

Shoulder pain *

Please specify the type and location of shoulder pain you suffer from.

Wrist pain *

Please specify the type and location of wrist pain you suffer from.

Elbow pain *

Please specify the type and location of elbow pain you suffer from.

Knee pain *

Please specify the type and location of knee pain you suffer from.

Ankle pain *

Please specify the type and location of ankle pain you suffer from.

Foot pain *

Please specify the type and location of foot pain you suffer from.

Waiver of Liability

1. Statement of Awareness:
Physical activity, by its very nature, carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. d Pilates has facilities for and provides services for activities such as weight lifting, walking, jogging and running, aerobic activities, and athletic activities. Some of these activities involve strenuous exertions of strength using various muscle groups, some activities involve quick movements involving speed and change of direction, and other activities involve sustained physical activity, which places stress on the cardiovascular system. The specific risks vary from one activity to another, but in each activity the risk of injuries range from (1) minor injuries such as scratches, bruises and sprains to (2) major injuries such as loss of sight, joint or back injuries, concussions, and heart attacks to (3) catastrophic injuries including paralysis and death.

2. Assumption of Risk:

a. Client understands that medical clearance is recommended before beginning any exercise program and that consultation with my physician to gain clearance to begin a fitness program is Client’s responsibility and highly recommended by d Pilates.

b. Client has read the Statement of Awareness and acknowledges the nature of the activities at d Pilates and Client understands the demands of those activities relative to Client’s physical condition and skill level, and Client fully appreciates the types of injuries, which may occur as a result of activities made possible by d Pilates. Client hereby asserts that Client’s participation is voluntary and that Client knowingly assumes all such health and injury risks.

3. Waiver of Liability:
In consideration of permission to use, today and on all future dates the property, facilities, and services of d Pilates, Client on behalf of Client, Client’s heirs, personal representatives, or assigns, do hereby release, waive, discharge d Pilates, d Pilates directors, officers, employees, volunteers, interns, independent contractors, and agents from all liability, and covenant not to sue, from any and all claims arising from the ordinary negligence of d Pilates or any of the aforementioned parties. This agreement applies to (1) personal injury (including death) from accidents or illnesses arising from the participation in d Pilates activities including, but not limited to, organized activities, group classes, observation, and individual use of facilities, premises, or equipment; and to (2) any and all claims resulting from the damage to, loss of, or theft of property.

4. Indemnification and Hold Harmless:
Client agrees to HOLD HARMLESS AND INDEMNIFY d Pilates from all claims resulting from negligence and to reimburse any expenses incurred by d Pilates in investigating and defending a claim or suit if Client’s claim is withdrawn, or to the extent a court or arbitration determines that d Pilates is not responsible for the injury or loss.

5. Severability and Venue:
The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by the law of the State of Texas and that if any portion thereof is held invalid, both parties agree that the balance shall, notwithstanding, continue in full legal force and effect. Likewise, Client agrees that if legal action is brought, the action must be brought in the State of Texas.

6. Acknowledgement of Understanding:
Client has read this waiver of liability and indemnification agreement and fully understands and acknowledges its terms. Client understands that Client is voluntarily giving up substantial rights, including my right to sue. Client acknowledges that Client is signing the agreement freely and voluntarily, and intends Client signature to be a complete and unconditional release of all liability to the greatest extent allowed by law in the State of Texas.

Please print out and sign our Waiver of Liability.

Payment Authorization

Please print out and sign our Payment Authorization form and bring it with you OR use the form below to authorize payment.

Payment Amount *

Payment Type *

Cash

Check

Credit Card

Begin Payments On: *

Payments End On: *

Credit Card Type *

Visa

Master Card

American Express

Discover

Credit / Debit *

Credit

Debit

Name (as it appears on card): *

Credit Card Number *

Experation Date *

CVC Code *

Billing Address *

Apt, suite, etc.

Country

City

State

Zip code

I authorize d\'Pilates to automatically charge each session fee per the d\'Pilates billing Policies. Should I request and obtain additional services from d\'Pilates, I authorize the charges associated with those services to be submitted for payment via my Card noted above.

Acknowledgements *

Waiver of Liability, Indemnity Agreement

Session Cancellation

Client Payment Authorization

By clicking below, I acknowledge that I have read and agree with the d\'Pilates policies concerning: