Pilates for Runners Enrolment Form General DetailsName First Last Date Of Birth Date Format: DD slash MM slash YYYY Address Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone NumberEmail Address GP Name / AddressEmergency Contact NameEmergency Contact Phone NumberAimsHave you ever done pilates before? Yes No If yes, how recently?How often do you run and what distance?What is your weekly running mileage?Are you training for any running events? When and what distance?Have you had any recent or chronic injuries? (State when and where)LifestyleWhat is your occupation?Does your job/lifestyle include any of these? Sitting for long periods Driving Bending Prolonged standing Lifting Repetitive movements Other than Running, what sports / activities are you involved with?Health QuestionnaireAre you currently experiencing or have you been diagnosed by the doctor with any of the following?CTRL click to select multiple optionsLow back painPelvic painNeck painAny other joint painAny spinal conditionHeart problemsEpilepsyNumbness or pins and needlesHigh or low blood pressureAsthma or breathing problemsHearing or visual problemsDiabetesCancerGlaucomaOsteoarthritisOsteoporosisAre you pregnant? Yes No If so, how many weeks?Is there a specific movement or position which causes you pain?If you have had neck or back pain, when was your most recent episode?Have you had any recent surgery? (State when and what type)Are you taking any medication currently? (If so please list)Informed ConsentPilates exercises are essentially very safe however there exists a minor possibility of certain dangers when exercising. While every care is taken to minimise these risks by evaluating the information you have provided in this form, predicting the exact response to exercise is impossible. The classes are not a substitute for medical treatment and it is wise to consult your doctor before starting the classes if you do not take regular exercise. The instructor can accept no liability for personal injury related to class participation if: A) Your doctor has, on health grounds, advised you against such exercise. B) You fail to observe instructions on safety or technique. C) Such injury is caused by the negligence of another participant in the class. I understand that the Pilates program will begin at a low level and be advanced according to levels of ability or fitness. The exercises may be stopped in the case of fatigue or discomfort. I agree to inform my instructor before any session if for any reason my health or ability to exercise has changed. Name (Print) First Last Date Date Format: MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.