Name * First Name Last Name Age DOB Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email * Name of person to contact in an Emergency How are they related Option 1 Option 2 Related Mobile Number (###) ### #### Tick the box if applicable & give details High or Low Blood pressure? Any Heart/Stroke Condition? Epilepsy? Asthma? Back injury or problem? Neck injury or problem? Shoulder injury or problem? Arthritis? Any other injuries or conditions that will limit your exercise program? If you ticked any of the above, please provide further details. Do you suffer from muscular cramps? If yes, where? Are you seeing a Physiotherapist OR Osteopath? If yes, please provide details so I can follow up with your care Your Fitness Goals Do you consent to your email to be included on our data bases Rancan Sisters Pilates and Rancan Sisters Fitness, for upcoming events, news and information? Your information will never be shared with any other party. Yes No I am willing to participate in an exercise program and exercises at my own risk. On this form I have clearly stated and outlined any physical condition, disability or any predisposition to sickness or injury. I take full responsibility or any injury, loss or damage to my person that may arise directly or indirectly from my participation in exercise sessions by Lisa Rancan. I will not penalise, prosecute or claim compensation from Lisa Rancan and or Rancan International Pty Ltd. This Health Waiver Is confidential Thank you!
