Name
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First Name
Last Name
Email
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Phone
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(###)
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Preferred method of communication
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Text
Email
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you have medical clearance to exercise? (Required to begin training)
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OB/GYN or Midwife’s Name:
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Age
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# weeks pregnant
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Due date
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MM
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YYYY
Are you having multiples (if so, how many)?
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Baby’s gender (optional)
Have you ever been pregnant before? If so, how many times? Have you experienced any pregnancy loss?
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Names/ages of other children (if applicable)
Do you have any lingering issues from previous pregnancies (pain, incontinence, core issues, etc.)?
How are you feeling physically so far (nausea, fatigue, energy level, etc.)?
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Do you have any pains or injuries that arose during pregnancy? If so, how long have you been experiencing them, and have you sought any diagnosis or treatment from a medical professional or physical therapist?
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Did your doctor or medical provider give you any exercise guidance or restrictions? If so, what is the rationale?
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Do you experience accidental urine leakage during sudden movements (coughing, laughing, sneezing) or during exercise? If so, do you know when this started and what activities it tends to occur with?
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Do you have a vision for the type of delivery you would like to have (hospital vs. home birth, unmedicated, epidural, planned C-section, etc.)?
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Do you plan to take any classes or work with any other experts to prepare for labor and early postpartum (i.e. birthing classes, working with doula)?
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Do you have any other (non-pregnancy related) pains, injuries, or medical conditions?
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Have you ever had a major surgery or injury? If so, does it still impact you today?
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Please describe your pre-pregnancy physical activity or exercise routine (# days/wk, intensity, exercise type, etc.).
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Please describe your pregnancy physical activity or exercise routine (# days/wk, intensity, exercise type, etc.). If different than pre-pregnancy, what is primary reason (i.e. not feeling well, nervous about what to do, body changing, etc.)?
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What is your occupation? Approximately how many hours would you say you spend sitting each day?
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What is your current sleep pattern? How many hours do you get per night? Has pregnancy changed your sleeping habits?
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How are you feeling mentally?
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What is your current stress level on a scale of 1 (no stress) to 10 (severe stress)? What are your primary sources of stress?
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Do you have any favorite hobbies or activities you like to do?
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What are your specific goals for this training program? If multiple, rank in priority order.
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Outside of your training days, can you commit to doing other physical activity (i.e. walking, elliptical, etc)? If so, what types of movement/cardio activities do you like doing?
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Anything you’d like me to know (i.e. what motivates you, what doesn’t)?
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Release and Waiver of Liability Form
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1. I am participating in yoga classes, strength sessions, health programs, workshops and/or other wellness, body work, exercise and healing arts activities (collectively, the “Activities”) offered by Jennifer Sbrocchi (the “Teacher”). The Activities may be offered in the physical location of choice or offered online by videos, television, podcasts, apps or other digital media or platforms. All of such offerings, either physical or online, shall be considered “Activities.”
2. I recognize that I must be in adequate physical and mental health to participate in the Activities. I understand that the Activities may require intense physical exertion, and I represent and warrant that I am physically fit enough to participate, and I have no medical condition which would prevent my full participation in the Activities. I recognize that the Activities may cause or aggravate a physical injury or medical condition. I understand that it is my responsibility to consult with a physician before my participation in the Activities. If I have done so, I have taken the physician’s advice. I understand that the Teacher reserves the right to refuse my participation in any Activities on medical, fitness or any other grounds.
3. I understand that information pertaining to labor, delivery or prenatal/postpartum health offered by the Teacher, does not constitute actual medical advice. I agree to not act on any information without first consulting with a physician.
4. I am aware that my participation in the Activities could result in high blood pressure, fainting, heartbeat disorders, physical injury, heart attack or stroke and may aggravate pre-existing injuries. I understand that I could experience muscle, back, neck and other injuries as a result of my participation in the Activities. I understand my physical limitations and I am sufficiently self-aware to stop or modify my participation in any Activities before I become injured or aggravate a pre-existing injury.
5. In consideration of being permitted to participate in the Activities, I agree to assume full responsibility for any risks, injuries or damages, known or unknown, which I might incur as a result of participating in the Activities, including those which may result from the negligence of the Teacher.
6. In further consideration of being permitted to participate in the Activities, I knowingly, voluntarily and expressly waive any “Claim” (as defined below) I may have against the Teacher and any of Teacher’s employees, independent contractors or assistants (each, a “Released Party”) that I may sustain as a result of participating in the Activities even if the Claim arises from the negligence of Released Party or anyone else.
I agree to indemnify and hold harmless Released Party from any loss, cost, or liability incurred in defending any Claim made by me or anyone making a Claim on my behalf, even if the Claim is alleged to or did result from the negligence of Released Party or anyone else.
“Claim” includes but is not limited to any and all liabilities, claims, demands, expenses, fees, legal actions, rights of actions for damages, personal injury, mental suffering and distress, or death that I may suffer, my spouse, children or unborn child may suffer (including any legal fees or expenses) in connection with participation in any Activities.
7. I, my heirs or legal representatives forever release, waive, discharge and covenant not to sue any Released Party for any Claim caused by any negligence or other acts of any Released Party.
8. I hereby understand that the Teacher from time to time may photograph, video, or otherwise record Activities and place such photographs and videos on its Website or social media platform. I hereby consent to the use of my image that may appear in any such photograph or video.
9. The Activities are 60 minutes in length. Scheduling of the Activities must be made at least 3 days prior to the scheduled class time. Price of the Activities will be communicated prior to scheduling. Payment is due 24 hours prior to the scheduled class. Payment can be made by cash, check made out to Jennifer Sbrocchi, or via Venmo @TheNestEgg. If participating in virtual class, once payment is received, Zoom link will be sent to the participant.
10. The Activities are non-refundable and non-transferable. In the event that either you or Jennifer Sbrocchi need to cancel a class, both parties are responsible for canceling with at least 24 hours notice, unless cancellation is due to concerns of COVID-19, weather, terrorism, civil unrest, health changes, personal emergencies or otherwise.
11. Any notice to be given to Jennifer Sbrocchi shall be in writing via text or email message. I will send all text messages to the following phone number: (516) 841-7120 and all email messages to the following email address: jennifersbrocchiyoga@gmail.com.
12. This agreement shall be construed in accordance with, and governed by, the laws of the State of New York and that all actions, suits, claims and proceedings relating to this agreement shall be brought in a court of competent jurisdiction located in New York. In case any provision of this agreement shall be held invalid, illegal or unenforceable, it shall not affect any other provision of this agreement and this agreement shall be construed as if such provision had never been contained herein.
Date of Electronic Signature
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MM
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