Beautifully Balanced Registration Form Mini Morning Classes Question Title * 1. What's your contact details? Name * City/Town Country Email Address * OK Question Title * 2. How did you hear about Beautifully Balanced? From a friend A poster On Facebook On Instagram Internet search Zumba.com Other (please specify) OK Question Title * 3. Which services are you interested in? Yoga classes Zumba classes Wellbeing Workshops Reiki Treatments OK Question Title * 4. What are your main wellbeing goal(s)? Select up to 3. Reduce stress Improve posture Build confidence Lose weight Build strength Tone-up Socialise Time for yourself Switch mind off Improve fitness Increase flexibility Other (please specify) OK Question Title * 5. Do you currently have any of the following? None Low blood pressure High blood pressure Severe anxiety and/or depression Joint complaint Back problems Fracture/ sprain Arthritis Heart complaint Faint or dizziness Epilepsy Pregnant Given birth in the last 6 months Nursing/ Breastfeeding Haemophilia Receiving radiotherapy/ chemotherapy Respiratory or circulatory problems Diabetes Surgical operation in the last 6 months Other (please specify) OK Question Title * 6. In relation to Q5, do you confirm that you have consulted with a healthcare professional about your ability to exercise and that you are fit to participate? I ticked 'None' in Q5 Yes No If Yes, please note relevant details, e.g. of any restrictions on your physical activities given. If No, please consult with a healthcare professional before you start classes. OK Question Title * 7. How can we keep in touch? Monthly newsletter and marketing updates via email Monthly newsletter only via email Marketing updates only via email None OK Question Title * 8. Declaration: *I have answered these questions to the best of my belief and know of no other reason why I should not partake in exercise or treatment*If in any doubt, I understand that I should seek medical approval/advice before commencing with Beautifully Balanced*I will inform my instructor (or therapist) if my medical condition changes in the future*I understand that all exercise carries a risk of injury*I accept responsibility for my own body and I will stop if I experience any pain *I understand that the instructor (or therapist) will not be held responsible for any accident or injury. Yes No OK DONE