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Children Registration form
complpilates
2024-10-01T13:48:01+01:00
Registration form for Children
"
*
" indicates required fields
Consent
*
I confirm that I am the legal guardian/parent of the below mentioned client
I consent for the below client to participate in clinical equipment Pilates at Complete Pilates
I understand that the below client is U16 and it is my responsibility to pay upfront for the said client
I confirm that the below client is aged between 13-16 years and give my consent for them to attend sessions on their own without a legal guardian / parent present.
*
Yes
No
confirm that the below client is under the age of 13 and that a legal guardian / parent will be in attendance for the duration of the appointment.
*
Yes
No
General information
Name
*
First
Last
Date of birth
*
MM slash DD slash YYYY
Sex
*
Male
Female
Would rather not say
Contact telephone number for legal guardian / parent
*
Contact email for legal guardian / parent
*
Medical information
Is the client currently seeking medical attention for any injury, illness or pain?
*
Yes
No
If yes please give details below
*
Please give details below of current activity levels of the client
*
Please tick if the client has any of the following medical conditions
*
No medical concerns
Diabetes
Asthma
Epilepsy
Heart conditions
Lung disease
Osgood-Schlatters Disease
Diagnosed spine conditions
Sever’s disease
Any other
Diagnosed spine conditions - If yes please give details
*
Any other (please give details)
*
Please accept the below policies
*
I have read the
terms and conditions
I understand the
cancellation policy
I understand the
privacy Policy
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Name
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