Barre Client Consent, Health Screening, Disclaimer Form

First Name

Last Name

Contact Number:

Contact Email

Date of Birth:

Occupation:

Address

Address Line 1

Address Line 2

City

Country

Select

Postcode

Emergency Contact Name + Phone Number:

Please provide details/relevant info here:

Are you under the current care of a doctor/health professional? If yes, please give details

Current concerns in your body, health, well-being? If yes, give details

Experience of Barre/Yoga

Beginner
Intermediate
Experienced

By signing below, I agree to participate in classes/program. I have answered the Health Screening Form truthfully, with
my most accurate knowledge, that I am well to take part. I undertake to inform
Alice (Therapy by Alice Mooney) of any alteration to the above information. I will not hold Alice Mooney responsible for any negative states that I might experience either during or after classes/program and not hold Alice responsible for any loss, damage or
negative consequences that may result from taking part.
I understand that my personal data will be stored securely and confidentially.

Client Signature

To accept this agreement, type your name below

E-Newsletter Subscription

To receive a monthly newsletter from Therapy by Alice Mooney containing info on current classes, massage treatments, retreats & promotions please tick below

I subscribe

Thank You - See you in class soon!

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Barre Client Consent, Health Screening, Disclaimer Form

Thank you for contacting Therapy by Alice Mooney