I have enrolled in a program offered by Halcyon Fitness involving strenuous activity, including but not limited to aerobic dance, weight training, stationary bicycling, and the use of various pilates conditioning equipment (mat, reformer, Cadillac, chair, barrels, ladder barrel, fitness circle, dynamic bands, foam rollers, rotational disks, etc.) I am fully aware that the said program is strenuous and entails physical activity. Thus, I have consulted my physician and I am cleared to undergo the Pilates program (subject to any limitations indicated in the attached medical clearance)

Aside from the above, I am in good physical condition and do not suffer from any disability or debilitating medical condition that would prevent or limit my participation in this exercise program.

I hereby consent to undergo a postural analysis to help identify any muscular or postural imbalance. It is my understanding that the information will help my therapist/instructor choose the appropriate exercises and design my customized program.

I have been informed that the data obtained in this interview will be treated as privileged and confidential and will not be released to any other party without express consent.
I do, however, agree to use my information for research or statistical analysis, so long as the same does not provide facts that could lead to the identification of my person. Any other information obtained, however, will be used by the program staff to evaluate my physical status or needs.