PRIVATE or SMALL GROUP INSTRUCTION
REGISTRATION FORM

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Please Note:  Pressing the ENTER button submits the form.  Please use the TAB button or mouse to advance from one field to another.

  1. Please provide the following contact information:
    First Name
    Last Name
    Street Address
    City
    State/Province
    Zip/Postal Code
    Home Phone
    Work Phone
    Cell Phone
    FAX
    E-mail

     

  2. Which discipline are you registering for?

    Physiotherapy for Core Activation - Physiotherapy receipt provided.
    (By Appointment only - call 604-714-0999 to book an appointment)

    Dana will be going on maternity leave as of June 25th and returning March 2011.  The search for a replacement during her maternity leave continues.
    Prices (Effective as of Jan. 1, 2009)
     50 min. session - $100 per session
    25 min. session - $65 per session

    Core Rehab Class: Must have had prior Physio assessment determine eligibility.
    (Call 604-714-0999 to book appointment)     Physiotherapy receipt provided.
     Minimum of 3 clients required for class to run.

    The current session ends of June 24, 2010.  Dana will be going on maternity leave as of June 25th and returning March 2011.  The search for a replacement during her maternity leave continues.

    Level 1 - new client to Core Rehab classes
    Wednesdays 7-7:50pm - 8 classes for $280

    Level 2 - completed Level 1 or approved by Dana
    Tuesdays 10-10:50am - 8 classes for $280
     Thursdays 5-5:50pm  - 8 classes for $280 - FULL
    Physio Stretch     Class: Must have had prior Physio assessment to determine eligibility.
    (Call 604-714-0999 to book appointment)     Physiotherapy receipt provided.
    Minimum of 3 clients required for class to run.

    Not currently available.

     Private Pilates (no Physiotherapy receipt)
    (By Appointment only - call     604-714-0999 to book times)

    Private session - $90 per session
    Private package - 5 sessions for $400 (3 month expiry)
     

  3. How did you hear about us?

  4. If by word of mouth who referred you?
    Name

     

  5. Do you have any health concerns that we should know about?
    Eg. Current or past injuries/pain (please describe), Asthma, Heart conditions, or high blood pressure.

  6. What is your occupation?

  7. How many hours a day do you spend sitting?

  8. How many hours a day do you spend standing?

  9. What other exercise programs do you currently participate in? (hold down "Ctrl" key to select multiple options)

  10. Are you currently a member of any sports teams?

    Yes No

  11. If Yes what sports?

  12. Are you currently receiving any treatment or therapy? (E.g. Physio, Chiro, Massage)

  13. Have you had any previous Pilates, Yoga or core training?

    Yes No

  14. If Yes please provide a few details (e.g. number of classes, videos etc.)

  15. What are your goals? What do you want to achieve?