Health Information–COVID-19 Information & Liability Waiver

Client Name: ______________________________________ Date: ______________________________ 

COVID-19 Information

1. Have you had a fever in the last 24 hours of 100°F or above? Yes ☐ No ☐ 

2. Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? Yes ☐No ☐  

3. Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? Yes ☐No ☐  

Consent for Treatment. I understand that, Pilates and movement therapy work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including COVID-19. 

I understand that wearing a mask during prolonged exercise is not recommended and can potentially be harmful. Signing this form, I acknowledge that I am aware of the risks involved from receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/Bodycentric and Fitnesswest LLC from any claims related thereto. I give my consent to receive treatment from this practitioner. 

Client Signature: ______________________________________________ Date: ____________ 

Parent or Guardian Signature (in case of a minor): _______________________

Date: ____________

www.bodycentric.life

(203).727.7359

Contract for Pilates and Wellness Counseling From 

BodyCentric

Our goal at BodyCentric to provide a client personalized wellness counseling to include Pilates, Aquatic exercise, cardiovascular conditioning, weight training, flexibility, and range of motion, as well as postural deficiencies and corrections. BodyCentric is dedicated to the overall success of each client’s personal health and fitness program.

1. Payment – payment      for personal training services will be billed up front prior to the date      of the first training session. Sessions      are non-refundable. 
2. Sessions – each session will be 55 minutes in length. Client agrees to be on time for each session. The session starts and ends when scheduled. If the client is late, the session will end as scheduled despite his/her lateness.

Once a session is scheduled between the client and BodyCentric it is the client’s responsibility to either attend the scheduled session or provide BodyCentric with at least twenty-four hours’ notice of cancellation. If the client cancels within twenty-four hours of the session, the client shall be responsible for the session. Exceptions may be made for illness or emergency at our discretion.

If you are on vacation, or unable to attend your specified number of sessions per week, you may use those sessions during another week that month if your desired time is available.

Sessions must be used in the month they are purchased unless an exception or other arrangements have been made by BodyCentric.

1. Physician’s Approval – client must fill out and submit the health history questionnaire form and medical clearance form along with this liability release and made part of the agreement together with any documents, reports, or other information provided by client’s physician or doctor.

BodyCentric has the right to refuse any session to a client at any time based upon his/her physical condition.

1. Waiver – the client is aware that BodyCentric sessions include strength, flexibility,  and aerobic exercise, which may be potentially hazardous activities. The  client also acknowledges that these activities involve a risk of injury and death. Accordingly, the client voluntarily consents to participate in BodyCentric Fitness and Wellness sessions, and assumes the acknowledged risks involved.

The client hereby waives, release, and forever discharges BodyCentric, its officers, agents, employees, representatives, and executors, from any and all responsibilities or liability from injuries or damages resulting from participation in a class. Client also agrees that BodyCentric its officers, agents, employees, representatives, and executors shall not be liable for any claim, demand, cause, or action of any kind whatsoever for, or on the account of death, personal injury, property loss, or damage resulting from participation in any session.

____________________________________      _____________ 

Client Signature                            Date

____________________________________          _____________

Witness / Principal of BodyCentric  Date