New Client

Please complete the following form prior to your first class.

Full Name *

First

Last

want in Do

Cell Phone *

Do you want to receive text message reminders? *

• Yes
• No

Email Address *

Do you want to receive email reminders? *

• Yes
• No

Do you want receive the newsletter? *

• Yes
• No

Date of Birth (Day and Month) *

Have you done Pilates before? *

• Yes
• No

What are your goals in attending Pilates classes? *

How active are you currently? *

How would you describe your health? *

In general, how you feel day to day?

Is there any medical history I should know about? *

Are there any movements you can't or should not do? *

How did you hear about Rogue Valley Pilates? *

• From someone I know
• Google Search
• Social Media
• Other

Person who referred you

I acknowledge and accept the risks, liability and responsibility of participating in Pilates voluntarily.

• I agree

Submit