Participant Health History ℹ Basic Information Health Information 👨🦲 Name* First Last 👶 Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country 📱 Phone📧 Email 👷♀️ Occupation ⚠ Emergency Contact InformationContact Name First Last PhoneEmail ❤ Detailed Health InformationPlease indicate whether you experience or have experienced any of the following: Arthritis Asthma Cancer Chest Pain Diabetes Fibromyalgia Headaches Heart Disease High Cholesterol Hypertension Child Birth Metabolic Disorder Neurological Disorder Osteoporosis Spinal Disorder Describe any current/past injuries, surgeries, pregnancies, significant medical or alternative treatments. Check all body parts involved. Specify right(R) left(L) or both(B)Describe your present physical condition, including any medications:Please check which of the following forms of care, if any, you are receiving: Physical Therapy Chiropractic Massage Acupuncture Other You selected, "Other" – please explain that form of care:List current physical activities (including sports, exercise, movement and martial arts):What brings you to Tonya Herrick Pilates? What are your goals?How did you hear about us?✅ Acknowledgement of Risks, Informed Consent and Liability Waiver and Release❌ Cancellation PolicyAs a courtesy to other clients, I understand that if I need to cancel a scheduled session, I will make every effort to notify Tonya Herrick Pilates LLC at least 24 hours in advance. Late or same day cancellations will be charged to class card or package. Tonya Herrick Pilates, LLC reserves the right to make any changes deemed necessary by our team, trip leaders, teachers or partners. In the rare case of a cancellation on the part of the Company (due to political unrest, dangerous weather, low sign-ups, pandemics, epidemics, or any other occurrence outside of the Company’s control), the Company will offer a transfer to another trip. 🤝 Responsible Travel Agreement It is the Client’s responsibility to obtain all required travel documents including Visas, passports, travel insurance, and other travel documents unless otherwise noted. For the benefit of everyone on the trip, Tonya Herrick Pilates, LLC (Company) reserves the right to accept or reject any participant at any time without liability, and in the event the Company determines, in its sole and exclusive discretion, that a participant is disruptive to the harmony of the trip, it may without any obligation to pay a refund or any other amount whatsoever, expel such participant from the trip. The Company will carry no responsibility or liability for any participant who leaves the trip prior to its conclusion or for any activity undertaken by any participant which is not included on the trip itinerary. 📷 Photo Release From time to time during the retreat, the Company’s staff members may take videos or photographs to use as promotional materials. Participation in the Company’s photography and videography is not required by any students. If Client chooses to not participate in these activities, Client must communicate with a staff member in advance and move to an area that is not being photographed or recorded. Otherwise, Client hereby gives consent to being the subject of any photographs or video recordings made during the retreat with the Company by Company staff, and Client grants permission for these materials to be published or posted in ways that promote the Company and future retreats, in the Company’s sole discretion. 📃 Aerial Waiver and Release 1. I represent that I am physically capable and of participating in aerial yoga suspension fitness provided by Tonya Herrick Pilates, LLC. 2. I understand the yoga and physical exercise, activity, or fitness program should not be taken without the consent of a doctor of physician and I am responsible for undertaking that consent. 3. I agree that I am engaging in the activity of yoga, fitness, and aerial suspension classes at my own risk. 4. I agree that I am voluntarily participating in the aerial yoga class and the use of premises and facilities provided and assume all risk of injury, illness, or death. 5. I agree that Tonya Herrick Pilates, LLC is not responsible for any loss or damage to personal property. 6. I understand that Aerial yoga may be extremely demanding and I take full responsibility for knowing, monitoring, and acting within my abilities, and learning and incorporating any modifications, necessary to proceed in a safe manor. 7. I agree that Tonya Herrick Pilates, LLC and it’s directors, instructors, assistants, and employees, shall not be liable or responsible to any injuries to me which may occur as a result of my use of all amenities and equipment provided. Including (a) sudden and unforeseen malfunctioning of equipment (b) Instruction by teacher or assist (c) slipping or falling while in the facility. 8. I acknowledge that I have read and understand the waiver and release and understand that it is a release of all liability. 9. I expressly agree that this release shall be binding up my heirs, executors, administrators, and assigns. By signing this waiver. I am stating that I do not have any of the following conditions: • easy onset vertigo • inner ear problems • severe balance issues • severe muscle spasm • severe neck or back pain • recent surgery • osteoporosis or bone weakness • glaucoma • very high or low blood pressure • propensity for fainting • recent concussion or head injury • obesity • severe arthritis • head cold, flu or sinusitis • hiatal hernia • disc herniation • pregnancy beyond the 1st trimester • recent stroke • radiculitis • cebral sclerosis • trauma • Botox within 24 hours Tonya Herrick Pilates LLC Release I hereby certify that I am voluntarily participating in a physical conditioning and corrective exercise program with Tonya Herrick Pilates. I hereby affirm that I have my physician’s approval, I am in good physical condition, and I do not suffer from any disability that would limit or prevent my participation in this program. After having had the opportunity to inquire in detail regarding all aspects of the program and to have had all questions with regard to the program satisfactorily answered, including any physiological and/or psychological changes which can occur, I certify that I understand the potential risks of the program. I agree to release from all liability and to indemnify Tonya Herrick Pilates LLC/Tonya Herrick, its officers, employees and all representatives from and against all claims, actions, judgments, costs, expenses, and demands with respect to injury, loss, death or damage to my person or property in connection with my taking part in the above-stated program. It is understood and agreed that this agreement is to be binding on myself, my heirs, executors, administrators and assigns. I certify that I have read and understood the above. Refund Policy Retreat Deposits and packages are non-refundable. If you cancel your retreat, and it’s within 120+ days of the retreat, a refund (minus the non-refundable deposit) may be issued “only if the retreat leader is able to sell your reserved spot prior to 90 days before the retreat”. 🖊 SignatureIntending to be legally bound, I hereby make this agreement on:* MM slash DD slash YYYY I agree to the above retreat contract.* First Last Δ
