Client Registration Form


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NEW CLIENT REGISTRATION FORM ( HARA STUDIO COPY, OFFICE USE PLEASE PRINT )

FULL NAME ...................................................................................................... D.O.B ( OPTIONAL ) ........................................... ADDRESS .................................................................................................................................................................................... ........................................................................................................................................................................................................ PHONE (HOME) ................................................................. PHONE (MOBILE) ................................................................... EMAIL ................................................................................................................. MAY WE SEND YOU EMAILS? : Y | N OCCUPATION ...................................................................... PHONE (WORK) ..................................................................... PRIVATE HEALTH FUND ........................................................................................................................................................ EMERGENCY CONTACT (NAME & PHONE) ...................................................................................................................... HOW DID YOU HEAR ABOUT THIS STUDIO? ....................................................................................................................

1. YOUR CURRENT INJURIES / ILLNESS / MEDICAL CONDITIONS? :

( LAST 12 MONTHS )

......................................................

................................................................................................................................................................................................................... 2. YOUR PREVIOUS INJURIES / ILLNESS / MEDICAL CONDITIONS? : ................................................................................. ................................................................................................................................................................................................................... 3. YOUR PREVIOUS SURGERIES? : ................................................................................................................................................... 4. ANY MOVEMENT RESTRICTIONS? : ............................................................................................................................................. 5. ANY UNDIAGNOSED PAIN / WHERE? : ...................................................................................................................................... 6. HOW DOES YOUR MEDICAL CONDITION OR INJURY AFFECT YOU? : ........................................................................... ...................................................................................................................................................................................................................... 7. MEDICATIONS? : ............................................................................................................................................................................... 8. CURRENT TREATMENTS? : ............................................................................................................................................................. 9. ARE YOU PREGNANT?* : Y | N WHEN ARE YOU DUE? : .................................................................................................... *Please inform Hara Studio if you do become pregnant so we can modify exercises for you.

10. WHAT IS YOUR BABY AND BIRTH HISTORY? : .................................................................................................................... ................................................................................................................................................................................................................... 11. CURRENT EXERCISE REGIME / FREQUENCY? : ....................................................................................................................

2/105 -107, WEST HIGH STREET, COFFS HARBOUR NSW AUSTRALIA

PHONE 02 66524462

BEYONDMOVEMENTSTUDIO.COM.AU

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NEW CLIENT REGISTRATION FORM ( HARA STUDIO COPY ) Our studio respects your right to privacy. We realise that is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our studio and to who it is disclosed. The policy of our studio is to follow these procedures: a) The information collected on this form will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing accounts to you as well as processing payments and writing to you about any issues affecting your treatment. Your email address will also added to our online newsletter and our online scheduling. b) Your payment history, treatment records and other written materials relevant to your treatment will be kept here safely in a locked filing cabinet. c) We may need to disclose your health information to your other health professionals if we feel it is necessary in the context of your treatment in this event please authorise your instructor to contact doctor/physiotherapist by phone or email to discuss your program and health concerns. Doctor / Physiotherapist : ........................................................................................................................................... Your health concerns? : ...............................................................................................................................................

I agree that the information I have given on this document is true and correct. I have read and understood all wording printed on this document and take full responsibility for my actions at any and all times on the premises of HARA beyond movement studio and during any workouts, classes, practice and use of equipment in any way whilst engaged in activities on the above premises. I agree to keep my instructor or therapist updated as to any changes in my medical profile and that there shall be no liability on the instructor/therapist if I fail to do so. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against HARA Beyond Movement Studio its employees or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise. I agree that payments are non refundable and non transferable. I understand that I must give 24 hours notice for cancellations of studio sessions or the full fee will be charged. I am aware that all studio private / duo / quad 10 blocks are strictly valid for 3 months. Class course blocks are strictly valid per 8 week term only, workshops and holiday classes are valid for use only during the set dates. Pre booked classes must be cancelled within 24 hours prior to class commencement, 2 cancelled classes makeup per term only. No makeups for vacations in group classes. If you are a NO SHOW to your booked class you will be charged in full. No exchanges or refunds are given unless with a doctor’s certificate stating that you are unable to continue your training for medical reasons. In the case of vacations, we will hold your studio, duo, quad and private purchased blocks for no longer than 2 weeks per school term. Exceptional emergency situations may be arranged separately. SIGNED : ...................................................................................................................... DATE : ......................................................

2/105 -107, WEST HIGH STREET, COFFS HARBOUR NSW AUSTRALIA

PHONE 02 66524462

BEYONDMOVEMENTSTUDIO.COM.AU

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NEW CLIENT REGISTRATION FORM ( YOUR COPY, PLEASE TAKE WITH YOU ) Our studio respects your right to privacy. We realise that is important that you understand the purpose for which we collect details about your health, as well as how this information is used at our studio and to who it is disclosed. The policy of our studio is to follow these procedures: a) The information collected on this form will be used for the purpose of providing treatment to you. Personal information such as your name, address and health insurance details will be used for the purpose of addressing accounts to you as well as processing payments and writing to you about any issues affecting your treatment. Your email address will also added to our online newsletter and our online scheduling. b) Your payment history, treatment records and other written materials relevant to your treatment will be kept here safely in a locked filing cabinet. c) We may need to disclose your health information to your other health professionals if we feel it is necessary in the context of your treatment in this event please authorise your instructor to contact doctor/physiotherapist by phone or email to discuss your program and health concerns. Doctor / Physiotherapist : ........................................................................................................................................... Your health concerns? : ...............................................................................................................................................

I agree that the information I have given on this document is true and correct. I have read and understood all wording printed on this document and take full responsibility for my actions at any and all times on the premises of HARA beyond movement studio and during any workouts, classes, practice and use of equipment in any way whilst engaged in activities on the above premises. I agree to keep my instructor or therapist updated as to any changes in my medical profile and that there shall be no liability on the instructor/therapist if I fail to do so. I agree that neither I, my heirs, assigns or legal representatives will sue or make any other claims of any kind whatsoever against HARA Beyond Movement Studio its employees or its members for any personal injury, property damage/loss, or wrongful death, whether caused by negligence or otherwise. I agree that payments are non refundable and non transferable. I understand that I must give 24 hours notice for cancellations of studio sessions or the full fee will be charged. I am aware that all studio private / duo / quad 10 blocks are strictly valid for 3 months. Class course blocks are strictly valid per 8 week term only, workshops and holiday classes are valid for use only during the set dates. Pre booked classes must be cancelled within 24 hours prior to class commencement, 2 cancelled classes makeup per term only. No makeups for vacations in group classes. If you are a NO SHOW to your booked class you will be charged in full. No exchanges or refunds are given unless with a doctor’s certificate stating that you are unable to continue your training for medical reasons. In the case of vacations, we will hold your studio, duo, quad and private purchased blocks for no longer than 2 weeks per school term. Exceptional emergency situations may be arranged separately. SIGNED : ...................................................................................................................... DATE : ......................................................

2/105 -107, WEST HIGH STREET, COFFS HARBOUR NSW AUSTRALIA

PHONE 02 66524462

BEYONDMOVEMENTSTUDIO.COM.AU