About
Speaking
Retreats
Workplace
Podcast
Resources
Rebellious Client Intake and Waiver Form
Read
Terms of Service
Your Name
Address
Phone Number
Your E-Mail
Date of Birth
Occupation
Emergency Contact
Emergency Contact Phone
Have you done Pilates before? If so, where and for how long?
What sports or physical activities are you currently participating in?
Is there any medical condition, previous or current injury, restriction and/ or medication we should be aware of?
What goals are you looking to accomplish with our work together?
How did you hear about us?
I agree that all use of Rebellious Int’l, LLC facilities and services shall be undertaken at my own risk, and that I am physically, mentally, and emotionally able to undertake any and all physical, mental and emotional exercises or have consulted a physician before participating. I also agree that Rebellious Int’l, LLC shall not be liable for any claims, injuries, or damages to me connected with the use of the services and/ or facilities, and I do hereby expressly release and discharge Rebellious Int’l, LLC from all such claims.
I hereby grant permission to Rebellious Intl LLC to use photographs and/or video taken of me in publications, news releases, online, newsletters and in other communications related to the company.
Yes
No
Your acceptance of the Services provided by Rebellious is subject to the Terms of Service (“Terms”) posted on our website. By signing below, you agree to these Terms, acknowledge that the Terms apply to your participation in the Services, and consent to participate in the Services.
Signature/Initials
Date
Form submission[]
Submit
Join Our Free Trial
Get started today before this once in a lifetime opportunity expires.
