New Client Registration Form
Thank you for your interest in Body Mind Fitness!
This form is an opportunity for me to get to know you before we begin Personal Training, Private Yoga or Small Group Classes. I want to make sure that you are getting the most out of your time, so the more I know quicker we can get to what you need.
All of your responses will be kept strictly confidential.
I am looking forward to working with you towards your goals.
How did you hear about Body Mind Fitness?
If you selected "other" please let me know here.
Address Line 2
Province / State / Region
Postal Code / Zip
Antigua and Barbuda
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Trinidad and Tobago
Bosnia and Herzegovina
United Arab Emirates
Papua New Guinea
Central African Republic
Sao Tome and Principe
May we contact you by email?
What type of service are you interested in?
Check all that apply.
Private Yoga Session
Online Private Yoga Session
Mobility & Strength
Small Group Yoga Classes
Pre- & Postnatal Yoga
Pre- & Postnatal Strength Training
Yoga for Pelvic Health
Please specify other:
Preferred day(s) & time(s) for Private/Skype Sessions only?
Health Risk Assessment
The following information will be used to help tailor your sessions to your physical needs.
Do you experience any of the following:
Please check all that apply.
Shortness of Breath or Chest Pain
Inhaler (if yes, please bring it to every class)
High Blood Pressure
High Cholesterol Level
Significant Bone/Joint/Muscle Pain*
Abnormal Resting EKG
*Please specifiy your bone/joint/muscle pain if you checked the box.
If you are Pregnant, how many weeks? Are you experiencing any pregnancy related ailments?
If you are postpartum, how many weeks? Are you experiencing any postpartum related ailments?
Are you currently taking any medication(s)?
Is there any additional information I need to know about your health history?
What does your typical week look like?
Please describe your routine, including but not limited to routine, hobbies, workload, schedule, kids activities that you take part in, exercise, etc.
How do you feel physically on a daily basis?
Where in your body do you feel like you hold the most tension?
How do you feel mentally and emotionally on a daily basis?
Please check all the words below that you would regularly use to describe yourself?
Please check all that apply.
What are you hoping to gain, achieve or discover through your session(s)?
Please be as specific as possible.
Thank you :)
1. In consideration of participating in the Activity, I agree and acknowledge that I am fully aware that participation in the Activity involves risks and I
accept all the risks of participating, even if the risks are created by the carelessness, negligence or gross negligence of a Released Party -as
defined below- or anyone else.
2.Claims includes but is not limited to any and all liabilities, claims, demands, legal actions, rights of actions for damages, personal injury or death in connection with participation in the Activity. Released Party means Dominique Gauthier, Body Mind Fitness, or any of its
affiliates, franchisees and their respective representatives, directors, officers, agents, employees or volunteer staff.
3. I agree and acknowledge that:
a. I am in proper physical condition to participate in the Activity, and am aware that participation could, in some circumstances, result in physical injury, serious physical injury or death.
b. I understand my physical limitations and am sufficiently self-aware to stop physical activity before I become ill or injured.
c. I am aware that if the Activity occurs outdoors, the streets adjourning the area of the Activity are open to regular vehicular traffic during the Activity and I will obey all traffic laws and regulations.
4. I accept full responsibility for any product or technology loaned to me as part of participation in this Activity and commit to return the same in good working order.
5. I hereby, for myself and for my heirs, next of kin, executors, administrators and assigns, fully release, waive and forever discharge any and all rights or Claims I may have, now or in the future, against any Released Party, even if the Claims are based on the carelessness, negligence or gross negligence of a Released Party or anyone else. Without limiting the foregoing, I further release any recourses which I may now or hereafter have resulting from any decision of any Released Party.
6.I agree not to sue any Released Party for Claims, even if the Claims arise from the carelessness, negligence or gross negligence of any Released Party or anyone else. I agree to indemnify -reimburse for any loss- and hold harmless each Released Party from any loss or liability -including any reasonable legal fees they may incur- defending any Claim made by me or anyone making a Claim on my behalf, even if the Claim is alleged to or did result from the carelessness or negligence of any Released Party or anyone else.
7. I am aware that there is no obligation for any person to provide me with medical care during the Activity. I understand and acknowledge that:
a. there may be no aid stations available for the Activity.
b. if medical care is rendered to me, I consent to that care if I am unable to give my consent for any reason at the time the care is rendered.
8. I am aware that it is advisable to consult a physician prior to participating in the Activity. If I have consulted a physician, I have taken the physician's advice.
9. I grant my permission to the Released Party and any transferee or licensee or any of them, to utilize any photographs, motion pictures, videotapes,
recordings and other references or records of the Activity which may depict, record or refer to me for any purpose -Likeness-, including commercial use by the released parties, their sponsors and their licensees. This permission is for use anywhere in the world and on the Internet and for an unlimited period of time. I understand and agree that I will not be compensated or receive additional consideration for consenting to the use of my Likeness and that I will not be given a chance to receive, inspect or approve the promotional or marketing material, messages and/or content that may use my Likeness.
10. No warranties or representations have been made to me about the Activity which are not stated on this form. I understand and intend that this document act as the broadest and most inclusive assumption of risk, waiver, release of liability, agreement not to sue and indemnity.
11. If any provision of this agreement shall be unlawful, void or for any reason unenforceable, then that provision shall be deemed severable from this agreement and shall not affect the validity and enforceability of any remaining provisions.
12. I have fully read and understand this agreement. I am aware that by signing this agreement, I am waiving certain legal rights I or my heirs, next of kin, executors, administrators and assigns may have against the Released Party.
13. I hereby acknowledge that I may be required to use an automobile to travel to and from the Activity or as part of the Activity. I hereby acknowledge that I have the authority to use such automobile and that the automobile is fully insured for use in the Activity. I accept full responsibility for the automobile and that use of the automobile in the Activity will be at my own risk.
I also understand that:
-All payments are non-refundable or transferrable for any reason, including, but not limited to vacation, illness and injury.
-The scheduling and content of activities may be changed on occasion.
-All N.S.F. cheques will be charged a $50.00CDN fee.
-I will notify instructors immediately of any pain and/or major discomfort felt during any activity.
-I am responsible for bringing my required equipment to every activity -where applicable.
-If I am pregnant or plan to become pregnant during course of the Activity, I will submit a ParMED-X for Pregnancy, a guideline for health screening prior to participation in a fitness class.
BY SIGNING BELOW, Participant accepts and agrees to the terms and provisions contained in this agreement.
I understand, accept, and agree to the terms and provisions contained in this waiver.
Terms & Policies
-Discounts cannot be combined with any other offer; only one discount per service/purchase.
Payments can be made by cash, cheque, e-transfer or by credit card.
-Classes and Sessions are 55 minutes unless otherwise denoted.
-First time participants, please arrive 10-15 minutes early to fill out a waiver.
Please arrive 5-10minutes before your class or session begins; doors will be locked once class begins.
-Life Happens and we understand. In the event that you cannot attend a class or an appointment, it can be made up as long as you give 24 hours notice. Any appointment missed, late cancelled, or changed without 24 hours notice will result in a charge equal to 100% of the reserved service amount. The appointment may be taken off a package or charged individually
-We offer a generous 'make-up' policy that allows you to attend any other regular scheduled class within the same session in which you are registered when space is available. Missed classes cannot be used as a discount toward future sessions.
-All classes and sessions are non-refundable and non-transferable.
-Personal Training & Private Yoga Packages expire 3 months after purchase, unless otherwise denoted.
-Please avoid use of perfumes, colognes and body sprays within the studio.
-Cell phones must be turned off while in the studio to give yourself and others around you a well deserved break.
-Please remove your shoes while inside the studio..
I understand, accept, and agree to all terms and policies
Body Mind Fitness Release & Waiver
Please type your name below as a digital signature that all information is accurate to the best of your knowledge, and that you have read and understood the Terms, Policies and Awknowledgements of the Release & Waiver.
Date of digital signature
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Hours by Appointment Only
4:00pm - 6:30pm
10:00am - 10:00pm
4:00pm - 6:30pm
10:00am - 10:00pm
4:00pm - 6:30pm
7:00am - 12:00pm
Body Mind Fitness
2454 Main St.
© 2018 Body Mind Fitness