New Clients

Waiver & Client Intake Form

Form version: August 2026

Please read the agreement below carefully, then complete and submit the form beginning at "Participant Acceptance." This must be completed before your first session. If you have any questions before signing, write to pozzi.marina18@gmail.com.

1. Voluntary participation and inherent risks

I understand that participation is voluntary and may involve physical exertion, balance challenges, stretching, resistance, contact with equipment, and other physical activity. Risks may include, without limitation, falls, muscle soreness, strains, sprains, aggravation of a known or unknown condition, equipment-related injury, and, in rare cases, serious injury. I understand that no activity is risk-free. I knowingly accept the inherent risks of participation and agree to follow safety instructions, use equipment only as directed, and stop and notify the Instructor if I experience pain, dizziness, shortness of breath, faintness, unusual discomfort, or any other concerning symptom.

2. Health status and medical clearance

I represent that the information I provide in this form is complete and accurate to the best of my knowledge. I agree to disclose conditions, symptoms, medications, pregnancy or postpartum status, injuries, surgeries, restrictions, or changes in health that may affect safe participation. I understand that I am responsible for obtaining medical clearance before participating when advised by a healthcare professional, requested by the Instructor, or reasonably appropriate for my circumstances. The Instructor may modify, pause, or decline participation when safety concerns arise.

3. Scope of services and no medical care

The services covered by this agreement are fitness and wellness services. They are not medical diagnosis, physical therapy, medical treatment, or a substitute for care from a licensed physician or other qualified healthcare provider. Any discussion of anatomy, pain, injury, posture, rehabilitation principles, or health is educational and does not create a physician-patient or physical therapist-patient relationship. No particular result is promised or guaranteed.

4. Assumption of risk; limited release

In consideration for being permitted to participate, I assume responsibility for injuries or losses resulting from the inherent risks of the activities or from my failure to disclose relevant information, follow instructions, or use equipment appropriately. To the fullest extent permitted by applicable law, I release and hold harmless the Instructor and Company from claims arising from those assumed risks. Nothing in this agreement releases any person or entity from liability that cannot lawfully be waived, including any liability that New York law prohibits from being waived.

5. Virtual and recorded/on-demand services

For virtual or recorded/on-demand participation, I am responsible for selecting a safe, clear space; using stable and properly maintained equipment; keeping children, pets, and hazards away; and choosing modifications appropriate for me. The Instructor cannot inspect my environment or provide immediate physical assistance. I will stop the activity if I cannot perform it safely. Recorded content is for the authorized client's personal, non-commercial use and may not be copied, shared, posted, sold, or distributed without written permission.

6. Third-party studios and equipment

Services may occur at independently owned studios or other locations. I agree to follow the host location's rules and understand that the Instructor and Company may not own or control the premises or all equipment. This agreement does not replace any separate agreement required by a host studio.

7. Emergency response

If an injury or medical emergency occurs, I authorize the Instructor to contact the emergency contact listed in this form and, when reasonably believed necessary, to contact emergency medical services. I understand that I am responsible for costs associated with emergency care or transportation and that this authorization does not obligate the Instructor to provide medical treatment.

8. Personal property and damage

I am responsible for personal property brought to a session. I agree to pay for damage to equipment or property caused by my intentional conduct, reckless conduct, or misuse contrary to instructions, ordinary wear and tear excepted.

Service & Attendance Policies

9. Booking and payment

Payment is due as communicated at booking. A session or class is confirmed only when the Instructor confirms the reservation and any required payment has been received. Rates, package inclusions, and expiration dates are those disclosed at the time of purchase. Packages and reservations are personal and non-transferable unless the Instructor agrees otherwise in writing.

10. Cancellation and rescheduling

At least 24 hours' notice is required to cancel or reschedule. Cancellations, rescheduling requests, or missed appointments within 24 hours of the scheduled start time may be charged at the full applicable rate or deducted from a package. An exception or credit may be granted at the Instructor's sole discretion and does not create an ongoing entitlement. If an exception requires a new studio booking, the client may still be responsible for non-recoverable room-rental costs disclosed by the Instructor.

11. Late arrival

Sessions end at the originally scheduled time even if the client arrives late. A client arriving more than 15 minutes late may be treated as a late cancellation when the Instructor determines that the remaining time is insufficient for a safe and effective session. The client should notify the Instructor as soon as possible of any delay.

12. Illness and communicable symptoms

A client with fever, active vomiting or diarrhea, an undiagnosed contagious rash, or other potentially communicable symptoms should not attend in person and should notify the Instructor before the scheduled start time. The standard cancellation policy applies unless the Instructor grants an exception. When appropriate and available, the Instructor may offer a virtual alternative or another accommodation.

13. Package expiration, refunds, and instructor cancellations

Sessions must be used by the expiration date communicated at purchase. Unused sessions generally expire and are non-refundable, except as required by law or expressly agreed in writing. A documented medical issue may be considered case by case. If the Instructor cancels a session, the client will not be charged and will receive a rescheduled session, account credit, or refund for that session, as appropriate. Instructor-announced absences may extend a package expiration date when confirmed in writing.

14. Minors

A participant under 18 may participate only with the written consent of a parent or legal guardian. The parent or guardian confirms authority to sign, accepts the terms on the minor's behalf to the extent permitted by law, and remains responsible for providing accurate health information.

15. Privacy and records

Contact, health, and intake information will be used to assess participation, communicate with the client, administer services, maintain business records, and respond to emergencies. It will be handled with reasonable care and disclosed only as authorized by the client, as reasonably necessary to provide the service, or as required by law. Wellness and fitness records held by the Company may not be protected by HIPAA. The client may request reasonable access to or correction of their information by contacting pozzi.marina18@gmail.com or +1 (551) 359-9811. Records may be retained as reasonably necessary for legal, insurance, safety, and business purposes. See also our Privacy Policy.

16. Governing law; severability; entire agreement

This agreement is governed by New York law. If any provision is held invalid or unenforceable, the remaining provisions will continue to the extent permitted by law. This document, together with written booking terms disclosed at purchase and any required host-studio agreement, constitutes the agreement regarding the matters it covers. Changes must be in writing.

17. Acknowledgment and continuing duty to update

I have had the opportunity to read this document and ask questions. I understand it affects legal rights. I agree to notify the Instructor of material changes to my health or contact information before future participation. This agreement remains effective for future covered services unless replaced or revoked in writing; revocation does not affect services already provided or obligations already incurred.

I confirm that I have read, understood, and agree to Sections 1–17 above, and that the information I provide in this form is accurate to the best of my knowledge.

Participant full legal name

Date of birth

Electronic signature (type your full legal name)

Today's date

If the participant is under 18

Complete this section only when the participant is a minor. A parent or legal guardian must sign on the minor's behalf.

Parent/legal guardian name

Parent/legal guardian electronic signature

Optional photo & video authorization

This authorization is optional. Declining it will not affect your eligibility for services. I authorize the Instructor and Company to photograph or record me during sessions and to use my image, likeness, and voice for the Company's website, social media, educational materials, and marketing. I understand the content may be publicly accessible and may be edited for length or format. I receive no compensation and may revoke future use in writing, although content already published or distributed may not be fully retractable.

Yes — I authorize photography or recording for public, promotional, or marketing use. No — I do not authorize photography or recording for public, promotional, or marketing use.

Client intake

If you are unsure whether something is relevant, please include it, or discuss it privately with the Instructor.

Preferred name (optional)

Pronouns (optional)

Home address

Email

Phone

Emergency contact — name

Relationship

Phone

Primary goals for Pilates, movement, fitness, or wellness

Current symptoms, pain, injuries, or movement concerns (include location, onset, and aggravating activities)

Health history & participation screening

For each item, select Yes or No. If Yes, please provide details below. This screening helps the Instructor plan appropriately; it is not a medical evaluation.

Has a healthcare professional ever told you that you have a heart or cardiovascular condition?

Yes No

Do you experience chest pain with activity or at rest, unexplained fainting, dizziness, or unusual shortness of breath?

Yes No

Do you have uncontrolled high blood pressure or another condition requiring medical supervision during exercise?

Yes No

Do you currently have a bone, joint, muscle, spine, neurological, or balance condition that may be affected by activity?

Yes No

Have you had surgery, hospitalization, a fracture, or a significant injury within the past 12 months?

Yes No

Are you currently receiving medical care, physical therapy, or other treatment relevant to participation?

Yes No

Are you taking medication that may affect heart rate, blood pressure, balance, alertness, pain, or exercise tolerance?

Yes No

Are you currently pregnant, recently postpartum, or aware of pregnancy-related restrictions or complications?

Yes No

Do you have osteoporosis/osteopenia, a seizure disorder, diabetes, a respiratory condition, or another condition requiring precautions?

Yes No

Is there any other reason you may need medical clearance or modifications before participating?

Yes No

Details for any Yes response (include diagnoses, dates, restrictions, and recommendations)

Relevant surgeries, injuries, medical history, or current treatment not already listed

Current medications relevant to safe participation (optional — you may list the purpose rather than the medication name)

Healthcare provider name (optional)

Provider phone/email (optional)

I understand that the Instructor may request medical clearance before I begin or continue participation if a safety concern arises.

Participant initials

Submit signed form

Prefer to complete this in person or by email instead? Write to pozzi.marina18@gmail.com.

Marina Pozzi Wellness LLC
New York, New York, United States