Client Intake Questionnaire

I hereby certify that the information that I have provided in the Client Intake Questionnaire above is true and correct to the best of my knowledge.

Payment & Cancellation Policy

• Cancellations and rescheduling must be done at least 24 hours prior to the class start time to receive a full refund or to apply your payment to a different session.

• Any cancellation and/or rescheduling requests received with less than 24-hour notice will be considered a "Late Cancel" and result in a forfeiture of your session fee.

• Sessions are non-transferable. If you cannot attend your scheduled session, no one may come in your place.

I have read and voluntarily agree to the Payment & Cancellation Policy terms and conditions stated above.

Minor Child as Participant

In the event that the participant listed above is under 18 years of age, parental/guardian consent is required for participation in Synergy Fusion's programs and offerings.

Informed Consent and

Waiver & Release of Liability

I have volunteered to participate in a program of progressive exercise and to retain the services of Synergy Fusion, LLC and its teachers to receive physical training. I assume all risk of injury from my participation. To that end, I acknowledge and agree to all of the following:

1. The exercise programs provided by Synergy Fusion LLC utilize yoga and Pilates techniques of muscle conditioning, strengthening, and stretching. During this exercise there exists potential for muscle soreness or stiffness, abnormal blood pressure, fainting, irregular heartbeat, and other severe injuries including the possible instance of heart attack and death. I assume all of the foregoing risks and accept personal responsibility for any other damages or other injuries I might suffer.

2. I know I have the right to choose what exercises I do or do not perform and may withdraw from any exercise at any time.

3. I understand that Pilates involves unique equipment that I may not be familiar with; that the equipment is constructed of moving parts, springs, and levers; and that the movement of my body and the apparatus could result in the possibility of falling or being trapped by the moving parts.

4. I understand that my clear and focused involvement is necessary for my physical improvement and safety.

5. I understand that my participation may require the instructor to move me or ask me to move my body in ways that are new to me, and it is possible that in these movements pain or injury may occur or be exacerbated.

6. I understand that it is my responsibility to communicate clearly and promptly with my instructor, telling the instructor of any pain, discomfort, medical findings, or physical limitations.

7. I understand that it is my sole responsibility to consult with a physician prior to my participation in Synergy Fusion LLC's offerings to determine my fitness level and safety of participation.

8. I understand that a doctor’s release will be requested to participate in an individualized Synergy Fusion LLC program if I have recently experienced a new injury/illness or if I am pregnant, post-partum, or have concerns of osteoporosis, multiple sclerosis, or other significant neurological or physical dysfunction.

9. I recognize and understand that there are risks of physical injury inherent in participation in any physical exercise program and that those risks are increased with the use of exercise equipment, particularly the unique equipment used in Pilates instruction.

10. I understand that exercise equipment, particularly the moving parts, may be subject to fatigue or other wear and tear that may not be readily apparent to the user or to the Pilates studio. I knowingly assume the risks involved in taking Pilates instruction, using Pilates equipment, and exercising at this location.

11. I hereby and forever release, discharge, and hold harmless Synergy Fusion LLC, its teachers, members, and employees from and against any and all liability to me, my heirs, and next of kin, for any and all claims, demands, rights of action, causes of action, losses, or damages on account of injury including death, caused or alleged to be caused in whole or in part by the negligence of Synergy Fusion LLC. I waive my right to sue any of the foregoing for any injuries I may sustain or losses I may incur whether known or unknown resulting from the physical activities described herein.

12. Synergy Fusion LLC, its employees, teachers, and members have not made any representation as to the nature and quality of the facilities or equipment to be used, or as to any other matter related to my participation in the foregoing activities.

By signing this document, I acknowledge that I have read and understand the inherent risks of participation in Synergy Fusion LLC sessions and voluntarily assume full responsibility for any injury, damage, or loss that may result from my participation in any Synergy Fusion LLC offerings. I hereby waive and release Synergy Fusion LLC, its owners, and its teachers from any and all liability, past, present, and future, relating to the services provided.