Name *

First Name

Last Name

Phone *

(###)

###

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Emergency contact number

(###)

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Has your medical practitioner ever told you that you have a heart condition or have you ever suffered a stroke? *

Yes

No

Do you ever experience any unexplained pains or discomfort in your chest at rest or during physical activity/exercise? *

Yes

No

Do you ever feel faint, dizzy or lose balance during physical activity/exercise? *

Yes

No

Have you had an asthma attack requiring immediate medical attention at any time over the last 12 months? *

Yes

No

If you have Diabetes (Type 1 or 2) have you had trouble controlling your blood sugar in the last 3 months? *

Yes

No

Are you pregnant? *

Yes

No

Do you have any other conditions that may require special consideration for you to exercise? *

Yes

No

Do you agree to TMMC using images or videos of you for marketing purposes? *

Yes

No

Liability Waiver *

Please read the following carefully. By participating in any class or personalised health and fitness program offered by Georgia Boehm, trading as The Mindful Movement Club you agree that: ❋ The program or classes are a form of physical activity and that there are inherent risks in undertaking any form of physical exercise. You do not suffer from any known disability or condition which would prevent or limit your participation in this exercise program or class. Your enrolment and participation is purely voluntary and in no way mandated by The Mindful Movement Club. ❋ You will disclose verbally prior to each session/ class commencing, any pre-existing conditions that may place you at a higher risk of injury or inhibit your ability to participate in a class, this includes, but is not limited to: injuries, pain or recent surgeries, pregnancies, heart conditions and any other condition that may be of concern. ❋ You will notify Georgia if you experience any feelings of discomfort, pain, dizziness, light-headedness or nausea throughout the session/ class and will immediately stop participating in the session/ class if requested to do so, this will be requested with your safety in mind. ❋ Recommendations or instruction provided during a group class may not be tailored for your particular skill or ability level and it is your responsibility to assess whether you are able or want to participate in all or part of a class. ❋ Classes may be recorded for promotional purposes. If you do not consent to the use of video or still images taken during the class for promotional purposes, please notify us prior to class. ❋ The Mindful Movement Club is in no way responsible for the safekeeping of your personal belongings while attending sessions/ classes. The Mindful Movement Club does not assume responsibility for any lost or stolen personal property. ❋ Neither yourself, your heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against The Mindful Movement Club or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise. You consent to, and agree to release The Mindful Movement Club from any claims, demands, and causes of action as a result of your voluntary participation and enrolment. This waiver will apply to all classes and sessions undertaken by you with The Mindful Movement Club. By booking you automatically agree to the above Terms and Conditions.

I have read and agree to the liability waiver

Emergency Medical Services *

I give permission for The Mindful Movement Club to seek emergency medical services for me should I become injured or ill, with the understanding that I am responsible for any expense incurred. If I am signing on behalf of a minor child, I also give full permission for any person connected with The Mindful Movement Club to administer first aid deemed necessary, and in case of serious illness or injury, I give permission to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well being of the child.

I agree

Cancellation Policy *

Personal training sessions ❋ Clients must provide a minimum of 24 hours' notice to cancel or reschedule a training session. ❋ If a client cancels or reschedules a session with less than 24 hours' notice, the session will be considered a "late cancel" and will be charged at 50% of the session fee. ❋ If a client does not show up for a scheduled session, the session will be considered a "no-show" and will be charged at the full rate. ❋ If a client needs to cancel or reschedule a session due to an unforeseen emergency or illness, the session will not be considered a late cancel or no-show, but the client must provide documentation of the emergency or illness (e.g. a doctor's note). Community classes ❋ Clients can cancel booked classes at any time with 12 or more hours’ notice without penalty. ❋ If a client cancels a class with less than 12 hours' notice, the session will be considered a "late cancel" and will be charged at the full rate. ❋ If a client does not show up for a booked class, the class will be considered a "no-show" and will be charged at the full rate. ❋ If a client needs to cancel a class due to an unforeseen emergency or illness, the class will not be considered a late cancel or no-show, but the client must provide documentation of the emergency or illness (e.g. a doctor's note).

I have read and agree to the cancellation policy