Lumen Wellness Studio - Health Information and Waiver 2026

Name of regular doctor

Doctor's phone number

Emergency contact name

Emergency contact phone

Emergency contact relationship to client

Medical history

Please be aware that our Instructors have no expertise in the field of medicine nor are they trained to detect serious medical problems. If you have any specific medical concerns, conditions or requirements you are advised to consult your Doctor before participation as to what specific restriction, if any, should apply to your condition and which activities and or exercises you should avoid. You are solely responsible for evaluating and assessing your own health and wellbeing and whether, in all the circumstances, you should access and use facilities and participate in classes.

Has your doctor ever told you that you have a heart condition or have you ever suffered a stroke?

Yes

Do you ever experience unexplained pains in your chest at rest or during physical activity/exercise?

Yes

Do you ever feel faint or have spells of dizziness or lose balance during physical activity/ exercise?

Yes

Have you had an asthma attack requiring immediate medical attention at any time over the last twelve months?

Yes

If you have Diabetes (type I or type II) have you had trouble controlling Blood Glucose levels in the last 3 months?

Yes

Any diagnosed muscle, bone or joint problems that could be made worse by physical activity/exercise participation?

Yes

Are you aware of any other medical conditions that may require special consideration for you to participate in physical activity/exercise?

Yes

If you have answered YES to any of the seven questions above, you are required to seek medical clearance from an appropriate allied health professional or medical practitioner prior to undertaking any exercise.

Please provide full details of condition/s ticked above (including how long ago)

Are you currently pregnant?

Yes

If yes, please provide details of your pregnancy and any complications or conditions

Have you been pregnant within the last 12 months (post partum)

Yes

If yes, please provide details of your post-partum recovery and any health considerations

Do you currently exercise?

Yes

What is the average duration of your exercise session?

Less than 30 minutes

30-60 minutes

60-90 minutes

More than 90 minutes

What is the average intensity?

Light

Moderate

Vigorous / high

Please provide an indication of your goals and preferences

Increase cardiovascular fitness

Very important

Somewhat important

Not important

Lose weight

Very important

Somewhat important

Not important

Increase strength

Very important

Somewhat important

Not important

Social - participate in group activities

Very important

Somewhat important

Not important

Other (please specify)

9. I grant my permission to the Released Party and any transferee or licensee or any of them, to utilise any photographs, motion pictures, videotapes, recordings and other references or records of the Activity which may depict, record or refer to me

I agree

I do not agree - and I accept responsibility for removing myself from class for filming activities

Sign & release

1. In consideration of participating in group training "Activity", I agree and acknowledge that I am fully aware that participation in the Activity involves risk and I accept all the risks of participating, even if the risks are created by the carelessness, negligence or gross negligence of a Released Party (as defined below) or anyone else.

2. "Claims" include but not limited to any and all liabilities, claims, demands, legal actions, rights of actions for damages, personal injury or death in connection with participation of the Activity. "Released Party" means all of the Activity participants, volunteers, instructors.

3. I agree and acknowledge that: a. I am in proper physical condition to participate in the Activity and am aware that participation could, in some circumstances, result in physical injury, serious physical injury or death. b. I understand my physical limitations and am sufficiently self-aware to stop the Activity before I become ill or injured.

4. I accept full responsibility for any equipment or technology loaned to me as part of participation in this Activity and commit to return the same in good working order.

5. I hereby, for myself and for my heirs, next of kin, executors, administrators and assigns, fully release, waive and forever discharge any and all rights or Claims I may have, now or in the future, against any Released Party, even if the Claims are based on the carelessness, negligence or gross negligence of a Released Party or anyone else. Without limiting the foregoing, I further release any recourses which I may now or hereafter have resulting from any decision of any Released Party.

6. I agree not to sue any Released Party for Claims, even if the Claims arise from the carelessness, negligence or gross negligence of any Released Party or anyone else. I agree to indemnify (reimburse for any loss) and hold harmless each Released Party from any loss or liability (including any reasonable legal fees they may incur) 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 carelessness or negligence of any Released Party or anyone else.

7. I am aware that there is no obligation for any person to provide me with medical care during the Activity. I understand and acknowledge that: a. There may be no aid stations available for the Activity b. if medical care is rendered to me, I consent to that care if I am unable to give my consent for any reason at the time the care is rendered.

8. I am aware that it is advisable to consult a physician prior to participating in the Activity. If I have consulted a physician, I have taken the physician's advice.

9. No warranties or representations have been made to me about the Activity which are not stated on this form. I understand and intend that this document act as the broadest and most inclusive assumption of risk, waiver, release of liability, agreement not to sue and indemnity.

10. If the provision of this agreement shall be unlawful, void or for any reason unenforceable, then that provision shall be deemed severable from this agreement and shall not affect the validity and enforceability of any remaining provisions.

11. I acknowledge and agree that I will only participate in reformer classes or use the reformer machine(s) in the studio whilst I my weight does not exceed 157kg - This weight is specified by the manufacturer as the weight limit for safe use of their reformer machines. should my weight exceed the specified limit I acknowledge the business owner will be happy to work out a plan regarding alternative options to support me to participate in the wellness activities offered at the studio.

12. I have fully read and understand this agreement. I am aware that by signing this agreement, I am waiving certain legal rights I or my heirs, next of kin, executors, administrators and assigns may have against the Released Party.

I also understand that:

The manufacturer of our reformers specify a weight limit of 157kg for the safety of users. I agree that I will immediaely cease participation in all reformer classes should my weight exceed 157kg.

I will notify instructors immediately of any pain and/or major discomfort felt during any activity.

If I am pregnant or plan to become pregnant during the course of the Activity, I will notify my instructors immediately prior to participation in a fitness class.

I declare that all the info I've provided is accurate & complete

Lumen Wellness Studio - Health Information and Waiver 2026

Medical history

Medical background

Physical activity

Please provide an indication of your goals and preferences

Sign & release

Lumen Wellness Studio - Health Information and Waiver 2026

Medical history

Medical background

Physical activity

Please provide an indication of your goals and preferences

Sign & release