Teen Medical History Form

Please complete this form as the parent/gaurdian on behalf of your enrolled Teen. All questions contained in this questionnaire are strictly confidential. Please answer questions honestly and with as much detail as possible. 

DD/MM/YYYY
Teen's Name *
Teen's Name
Emergency contact name *
Emergency contact name
Medical History
Please be as detailed as possible and include all relevant history including any surgical procedures.
If yes please provide details here.
Lifestyle and Goals
Our Liability *
You acknowledge and agree that CGM Pilates and our Representatives shall not be liable for any injury, illness, accident, loss or damage of any kind whatsoever suffered by your teen either directly or indirectly in connection with their attendance at or entering the Studio or participation in a Class or as a consequence of your Membership and you release CGM Pilates and its Representatives absolutely from any and all claims in connection therewith.