Consent form S&M

Health Pre Exercise & Registration Form - Stillness in Movement Program

Please complete the following. All information will be treated with the strictest confidence.
© Beverly Carter & It's Time To Shine Pty Ltd.

* Indicates required field

Program Name and Start Date *

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Phone Number *

Email *

Emergency Contact Person *

First

Last

Phone Number *

Occupation *

Car Registration *

Has your doctor said you have any sort of heart trouble or defect? *

Diagnosed/take medication for depression, anxiety, bi-polar or anything of this nature? *

Are you pregnant, or have had a baby in the last 6 weeks? *

Have ever been diagnosed with diabetes, epilepsy or stroke? *

Do you suffer headaches? *

Have you ever been told that you have arthritic joints/any bone or joint problem that would be made worse by exercise? *

Have you ever been told you have osteoporosis? Oesteopenia? *

Have you had any injuries or operations in the past 12 months? *

If yes please give details *

Is there any reason, not yet mentioned, that should stop you performing physical exercise? *

Very Important * If you have answered ‘YES’ to ANY of the above, please give further details below & provide medical clearance before commencing this program *

What would you like to feel from the Stillness in Movement program with Beverly *

Please advise Bev before commencing this program or, immediately if your ability to exercise changes throughout the program. If you have ticked YES to any of the above Bev will be personally in touch prior to the commencement of program.

N.B. It is inadvisable to commence Core and Abdominals exercises between 8 & 24 weeks of pregnancy and within 6 weeks of giving birth. Stillness in movement program will involve lying prone (on back) which is not recommended for later stages of pregnancy. For all pregnancy advise please contact Beverly directly

With all forms of physical exercise & coaching it is important to consult your doctor before you begin. This program is not a substitutes for medical counselling or treatment. If you have any doubt about the suitability of the exercises, you should refer back to your medical practitioner. Beverly Carter and It’s time to shine Pty Ltd cannot accept any liability for your personal injury related to participation, if :-

Your doctor has, on health grounds advised you against such exercise
You fail to observe instructions on safety & technique
Any injury caused by negligence of another participant

All program material/exercises/movements/programs/sequences The Stillness in Movement Program, Classes, private sessions along with IP and terms are copyright to It’s Time to Shine Pty Ltd and Beverly Carter and can not to be shared or altered in anyway. They are for the sole use of the client participating on the Stillness in Movement program or with Beverly Carter.

Payment is not refundable or transferable so please check all information/dates/times carefully.

I acknowledge that by not undertaking a health & fitness assessment, for my activities & exercise prescribed by Bev Carter It’s time to shine without, prior written approval by medical practitioner I do so at my own risk.

Notwithstanding the above recommendations, I hereby request I participate in the exercise, coaching & activity prescribed by Bev Carter It’s Time to Shine which I shall take entirely at my own risk. I hereby waive on behalf of myself and my heirs & executors any claim of any kind whatever which I or they may hereafter have against Bev Carter It’s Time to Shine for any injury, illness or adverse change in my medical condition or state of health (whether permanent or temporary) arising directly from my undertaking of the exercise, movement & activities provided by Bev Carter It’s Time to Shine.

I have read and understand the informed consent (parent/guardian if under 18yrs) *

Yes

Submit

Step 2 - Complete payment - Beverly will email you asap - if you do not receive email within 48hours of booking please contact [email protected]

Return to the booking page to complete Step 2 of your booking process.

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