TOTAL REHAB PILATES CLASS REGISTRATION FORM

Name___________________________________________________________________

Address_________________________________________________________________

Phone #_________________________________________________________________

Date of Birth ___/___/___ Date of Last Physical ____/____/____

Class times & dates- 10 classes in each session 1/week

Monday September 17, 2007 to Monday November 26, 2007

_______________________________________________________________________

Total cost is $116.60 ($11 per class plus GST)

Method of payment: Make cheques payable to Total Rehab

Credit card #___________________________ expiry__________

Cheque #______________________________

Cancellation and refund policy: Once sessions have begun, all fees are non refundable.

Waiver:

I ______________________ take full responsibility for my participation in this fitness class. I declare that I am of good health with no major risk of coronary heart disease, hypertension, or any orthopedic, metabolic, physical or mental conditions that may be aggravated by exercise. I understand it is recommended to obtain a medical release if I am male over 45, or female over 55 and have, or may have, significant risk factors for heart disease. I further acknowledge that I should not start an exercise program if I have recently become pregnant. I release and save harmless Total Rehab and its service providers from all claims or possible claims and I assume full risk of injury due to any ailments I may suffer while participating in this fitness class.

Signature:___________________________

Date:___________________________

Please complete this form to register for the Pilates class

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q)

Par-Q is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of PAR-Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life. PAR-Q has been designed to identify the small number of individuals for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.

Common sense is your best guide in answering these few questions. Please read them carefully and check the “yes” or “no” box opposite the question if it applies to you.

YES NO

1. Has your doctor ever said you have heart trouble?

2. Do you frequently have pains in your heart or chest?

3. Do you often feel faint or have spells of severe dizziness?

4. Has a doctor ever said your blood pressure was too high?

5. Has your doctor ever told you that you have a bone or joint

problem and exercise may aggravate it or make it worse?

6. Is there a good physical reason not mentioned here why you

shouldn’t follow an activity program even if you wanted too?

7. Are you over the age of 65 and not accustomed to vigorous

exercise?

If you answered, “Yes” to any of the above questions it is HIGHLY recommended that you consult your doctor before beginning this program. Pilates is a supervised program, however we recommend those new to our class and have answered yes to any of the above questions seek their doctors approval before they begin this or any exercise program.

While in class you should never strain your muscles. If you feel strained it’s an indication you’re not ready for that exercise and should go to an exercise your body can do without strain. Do not push your body past the point of comfortable movement. These exercises are meant to teach you a new way to connect to your body, not to conquer it. Learn them well and you will progress in no time. By signing the registration form you indicate and understand the risk and take full responsibility for your participation in this program. You should always take appropriate measures for your comfort and safety while participating in this exercise program.

Please initial that you read and understand the above statement:________________.

Thank you,

Total Rehab