Akila Pole Studio

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PAR-Q + Liability Waiver

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Have you been hospitalized in the last 12 months?

No

Yes

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

For any questions you have, you can reach us here:

AKILA POLE STUDIO

*Previously Pranayama Pole*

SW2 2DP

Full Address Provided Upon Booking*

Thanks for submitting!

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