Name *

First Name

Last Name

Phone *

(###)

###

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Birthday *

MM

DD

YYYY

In case of emergency number *

(###)

###

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Do you have a family history of heart disease, stroke, elevated cholesterol or high blood pressure? *

Yes

No

Do you have or have had any bone or joint problems? *

Yes

No

Have you recently had surgery? *

Yes

No

Are you on any prescribed medication? *

Yes

No

Are you pregnant, or have given birth in the last 3 months? *

Yes

No

Do you know of any reason why you should not do physical activity? *

Yes

No

Do you have any allergies? *

Yes

No

Informed Consent Form and Confidentiality Agreement *

Purpose and Nature of Activity I have voluntarily enrolled in Polecats Manila. I understand the class involves strenuous physical activity which includes, but not limited to, pole dancing, muscle strengthening, and flexibility training exercises designed to improve cardiovascular fitness, endurance, and fluidity of movement. During the course of the class, physical contact might be necessary for proper body positioning and alignment. I affirm that I am in good physical condition, and have no known condition which would limit my participation in the program. Benefits The level of exercise I will participate in will be according to my level of fitness. I understand that this program may benefit my general health and therefore raise my level of fitness. Risks I fully understand risks associated with exercise. I realize that I may injure myself during the program, and in consideration of this, I release Polecats, Inc from any liabilities that may result from my enrollment. I understand that I might experience redness, bruising, and soreness. It is my obligation to inform the instructor should any pain or discomfort arise from the activities. Confidentiality All information given here will be treated with confidentiality. Any other information obtained will be used by the staff for evaluation purposes only. Inquirires and Freedom of Consent The structure, purpose, benefits and risks of the class have been explained to me. I may ask questions about the class and/or program at any time, and I understand that I may withdraw from the class at any time. Confidentiality and Non- Disclosure All class content, including but not limited to teaching method, curriculum, discussions, written materials, movements, dance steps, routines, choreography ("Proprietary Information"), are the property of Polecats Inc and constitute confidential and proprietary business information and trade secrets. You agree to keep the Proprietary Information confidential and not to disclose the Proprietary Information to anyone without the prior written consent of Polecats Inc. You further expressly agree that you will not use the Proprietary Information for the purpose of soliciting any students or employees of Polecats Inc or to otherwise compete with Polecats Inc.

I have read and fully understand the informed consent and confidentiality agreement.