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Balanced Birch Studio - Client Intake Form - Studio Policies - COVID Acknowledgement
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Email *
First Name *
Last Name *
Street Address *
Town/City *
State *
Zip Code *
Phone Number *
Date of Birth *
Referred By
Interested In: *
Current Athletic/Daily Activities: *
Fitness Goals: *
Please list any health restrictions on your ability to participate in sessions (injury, surgery, medications): *
Emergency Contact/Relationship/Phone Number: *
Physician/Phone Number: *
Kindly note that we require 24 hours’ notice of rescheduling or cancellation (except in an emergency). Please arrive 15 minutes early to your session. Please silence cell phone during your session. Scents and perfumes are prohibited in class. *
Electronic Signature *
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