Stillness in Movement Consent Form

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Everyone who is participating in an It's Time to Shine class or program is required to fill out this form before the commencement of their first session with Beverly Carter.

First Name *

Last Name *

Email address - Please complete carefully *

Date of Birth

YYYY

Phone number *

Address Line 1 *

Address Line 2

Suburb / Town *

State / Province *

Postcode *

Country *

Occupation *

Emergency Contact Person

Full Name *

Phone number *

Has your doctor said you have any kind of heart trouble or defect? *

Yes

Diagnosed / take medication for depression, anxiety, bi-polar or anything of this nature? *

Yes

Have you ever been diagnosed with diabetes, epilepsy or stroke? *

Yes

Do you suffer or taking any medication for High or Low blood pressure *

Yes

Are you pregnant or have had a baby in the last 6 weeks? *

Yes

If you have answered YES to any of the above, please give further details below and provide medical clearance before commencing this class or program. *

Have you ever been told that you have arthritic joints/any bone or joint problem that would be made worse by exercise? *

Yes

Have you ever been told you have osteoporosis? Oesteopenia? *

Yes

Have you had any injuries or operations in the past 12 months? *

Yes

If you answered YES to the above question please give details

Please share any information that Bev Carter will need to support you throughout your program - including back issues, shoulder pain, tender knees etc *

Is there any reason, not yet mentioned, that should stop you performing physical exercise? *

Yes

What would you like to feel/be/develop through the Stillness in Movement program with Beverly Carter *

Please advise Bev before commencing this program or, immediately if your ability to exercise changes throughout the program.

Terms and Conditions - Please read carefully before payment

N.B. It is inadvisable to commence Core and Abdominals exercises between 8 & 24 weeks of pregnancy and within 6 weeks of giving birth. For all pregnancy advise please contact Beverly directly

With all forms of physical exercise & coaching it is important to consult your doctor before you begin. This program is not a substitutes for medical counselling or treatment. If you have any doubt about the suitability of the exercises, you should refer back to your medical practitioner. Beverly Carter and It’s time to shine Pty Ltd cannot accept any liability for your personal injury related to participation, if :-

Your doctor has, on health grounds advised you against such exercise
You fail to observe instructions on safety & technique
Any injury caused by negligence of another participant

All program material/exercises/movements/programs/sequences, Classes, private sessions along with IP and terms are copyright to It’s Time to Shine Pty Ltd and Beverly Carter and can not to be shared or altered in anyway. They are for the sole use of the client participating on the Stillness in Movement program or sessions with Beverly Carter.

I acknowledge that by not undertaking a health & fitness assessment, for my activities & exercise prescribed by Bev Carter It’s time to shine without, prior written approval by medical practitioner I do so at my own risk.

Notwithstanding the above recommendations, I hereby request I participate in the exercise, coaching & activity prescribed by Bev Carter It’s Time to Shine which I shall take entirely at my own risk. I hereby waive on behalf of myself and my heirs & executors any claim of any kind whatever which I or they may hereafter have against Bev Carter It’s Time to Shine for any injury, illness or adverse change in my medical condition or state of health (whether permanent or temporary) arising directly from my undertaking of the exercise, movement & activities provided by Bev Carter It’s Time to Shine.

Payment is not refundable or transferable so please check all details prior to your payment.

I have read and understand the informed consent (parent/guardian if under 18yrs) * *

Yes

Submit

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