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Balanced Birch Studio - Client Intake Form - Studio Policies - COVID Acknowledgement
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Email
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Your email
First Name
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Your answer
Last Name
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Your answer
Street Address
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Your answer
Town/City
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Your answer
State
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Your answer
Zip Code
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Your answer
Phone Number
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Your answer
Date of Birth
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YYYY
Referred By
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Interested In:
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Group Lessons
Private Lessons
Both
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Current Athletic/Daily Activities:
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Your answer
Fitness Goals:
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Your answer
Please list any health restrictions on your ability to participate in sessions (injury, surgery, medications):
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Your answer
Emergency Contact/Relationship/Phone Number:
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Physician/Phone Number:
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Kindly note that we require 24 hours’ notice of rescheduling or cancellation (except in an emergency). Please arrive 15 minutes early to your session. Please silence cell phone during your session. Scents and perfumes are prohibited in class.
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Checking this box acknowledges that you have read, fully understand, and agree to all of our studio’s policies.
Electronic Signature
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