Pilates & Yoga Registration Form

Completion of this form is mandatory for all new clients.

Personal Details

First Name(required)

Surname(required)

Address Line 1(required)

Address Line 2

Town(required)

County(required)

Eircode

Email(required)

Mobile(required)

The information provided in this form is for our personal use only and will be stored in a safe manner consistent with GDPR requirements.

Your email address is used primarily to contact you about your Pilates or yoga classes. We may also send you occasional updates or special offers regarding our other Pilates, yoga or massage services. You can unsubscribe from these updates at any time. If you do not wish to receive these updates, please tick below.

I do not wish to receive occasional updates or special offers via email.

Health Assessment

If you have ticked any items above, your instructor will review these with you before your first class. Sign-off from your doctor may be required before participating in class. Please add any additional details below:

Course Fees

Course fees are payable in full in advance. You can pay in advance by Revolut to 0876472551 or in cash on the first day. Please indicate your preference below.

Note that fees are non-refundable. If you cannot attend for any reason, please contact us and we will try to fit you in to another class. Note that space in all classes is strictly limited, so it may not be possible to accommodate you in another class.

I wish to pay by:

Cash Revolut

Release & Waver of Liability

Participation in our classes is at your own risk.

I acknowledge that participation in Pilates or Yoga exercise is strenuous physical activity which may include the use of equipment, and that such physical activities involve inherent risk of physical injuries or other damage including, but not limited to, heart attacks; muscle strains, pulls or tears; broken bones; shin splints; heat stroke; knee/lower back/foot injuries; and other illnesses, soreness or injury however caused, which can occur during or after participation in the physical activities. I further acknowledge that such risks include, but are not limited to, injuries caused by the negligence of the instructor or other person, defective or improperly used equipment, over-exertion by me, a slip or fall by me or an unknown health problem of mine. I agree to assume all risk and responsibility involved with my participation in these Pilates or Yoga classes.

I affirm that I am in good physical condition and do not suffer from any disability that would prevent or limit participation in the physical activities. I acknowledge that participation will be physically and mentally challenging and agrees that it is my responsibility to seek competent medical or other professional advice regarding any concerns involved with my ability to take part in the physical activities.

By signing this agreement, I assert that I are capable of participating in the physical activities and agree to assume all risk and responsibility for exceeding my own physical limits. I agree to fully release June Molloy Wellness from any and all liability, claims and/or litigation actions that I may have for injuries, disability or death or other damages of any kind including, but not limited to, punitive damages, arising out of participation in the physical activities, even if caused by the negligence, intentional acts or omissions and/or any other type of fault of June Molloy Wellness.

Declaration

I undertake not to attend classes if I have (or suspect I have) Covid 19(required)

I declare that I am currently free from injury and sufficiently recovered from any injury, surgery or illness to partake in Pilates or Yoga classes. I have consulted with my GP and/or Physiotherapist, as appropriate.(required)

I hereby affirm that I have read and fully understand the above, am over eighteen years of age and am legally liable for my own decisions/actions. By signing below, I confirm that I agree to the terms indicated on this form.(required)

Digital signature – type your name in the box below(required)

Date(required)