Name:____________________________________                   Birth date: ____________

Address: ___________________________________________________      (J/M/A - D/M/Y)

Telephone: ____________________________ Cell: ___________________________

Email: __________________________________________

 

In case of emergency                                                

 

Name: _______________________________________ tel: ___________________

What is your goal in practicing Essentrics?

___​ Stress reduction

___​ Overall sense of wellbeing

___​ Muscle Toning                            

Are you currently experiencing any of the following medical conditions?

(check & circle)                            

____ High/ Low Blood Pressure

____ Respiratory / Circulatory Problems

____ Neck / Back / Spine Injury

____ Dizzy spells / Fainting / Epilepsy /Seizures

____ Menopause / Pregnancy

____ Headaches / Chronic Pain / Fatigue

 

Are you currently taking medication, seeing a therapist/physician, receiving other alternative forms of health treatment? Yes ____ No _​__​_ If yes, please indicate here: _________________________________________________________________________                                   

Have you ever practiced Essentrics before? Yes _​__​_ No ___ When/Where? __________________________________________________________________________       

We occasionally have a camera in the studio. Would you be OK to have your photo used in future marketing efforts? Yes _​___​_ No ____

 

If at any time during the Essentrics class you feel discomfort or strain, gently come out of the posture and inform your instructor. You may rest at any time during the class.  It is important that you listen to your body, and respect its limits on any given day.  It is equally important to inform the instructor of any discomfort or problems you are having.

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Professional Disclaimer Waiver

 

To the best of my knowledge I am in good physical and mental condition and am capable of participating in this Essentrics class.  I am not aware of any physical or mental illness or injury that prevents me from participating in Essentrics.

 

I, the undersigned, understand that Essentrics is not a substitute for medical attention, examination, diagnosis or treatment. I know the importance of consulting a physician prior to beginning any physically active program, including Essentrics. I recognize that it is my responsibility to notify my instructor of any illness or injury before every Essentrics class. I will not perform any postures or participate in Essentrics classes to the extent of strain or pain.

 

I accept that neither the instructor, nor the hosting facility is liable for any injury, or damage, to person or property, resulting from the taking of the “live online” class and/or “in-person” class.

 

This Waiver and Release of Liability form shall remain effective until it is revoked in writing by the client.

 

____________________________________________       ________________________

Signature * Those under 18yrs of age require a signature by a parent or guardian.         Date

 

____________________________________________

* Please print name of parent or guardian here

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COVID-19 Waiver and Disclaimer

 

I understand that the doors will be locked at class start time and I will not be able to participate if I arrive past this time. I accept that should I cancel later than 12 hours before class or not show-up to class as a drop-in participant, that I will be charged the regular drop-in fee of $15 (unless there is concern that I am showing any signs/symptoms of COVID-19 and have contacted my instructor prior to class).

 

Are you experiencing any of the following symptoms: fever/feverish, cough, sore throat, headache, runny nose, a new cough or worsening chronic cough, new onset of fatigue, diarrhea, loss of taste/smell? ___ YES ___ NO

 

Have you had close contact within the last 14 days with a confirmed case of COVID-19?  ___ YES ___ NO

 

Have you been diagnosed with COVID-19? ___ YES ___ NO

 

Have you returned from travel outside of the Atlantic Bubble (New Brunswick, Nova Scotia, PEI, & NFLD) within the last 14 days? ___ YES ___ NO

 

Have you been told by public health that you may have been exposed to COVID-19?  ___ YES ___ NO

 

If you have answered YES to any of the above questions, or are experiencing any one of the above symptoms, we require that you abide by the NB COVID-19 guidelines.

 

I acknowledge that I am attending the classes at my own risk in light of the COVID-19 pandemic.

 

I am aware of the risks associated with potential exposure and transmission of the virus and will take all government- recommended precautions when entering the facility in order to protect myself and others.

 

I have read and understood these guidelines and accept my responsibility to abide by social distancing protocols. I will also inform Nancy Gould immediately should there be any changes in the health screening questions or possibility that I have been exposed to the virus or been in contact with a potential carrier.

 

____________________________________________       ________________________

Signature * Those under 18yrs of age require a signature by a parent or guardian.         Date

 

____________________________________________

* Please print name of parent or guardian here

____ Digestive / Urinary Problems

____ Muscular / Tendon / Joint Injury or Pain

____ Eyesight Problems

____ Arthritis / Hearing Loss

____ Depression, Anxiety / PTSD

Other: _​___________________________​

___​ Flexibility

___​ Strength

Other____________________________