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Realign Therapy Registration Form

For any questions, please email RealignTherapyOntario@gmail.com

Hosted at: The Healing Nook Holistic Wellness Hub

7 Russell St. W. Smiths Falls, ON

Listed below are you'll find: All Workshops & Classes - Choose what you would like to attend! ✔️Check the boxes of all those that apply.

🎫Join Workshops & Events:

Movement for Menopause🔸Sunday August 30th at 1pm 🔸 $55 (Registration Closed)

❇️Register for Group Exercise Therapy & Personal Training Classes

Covers topics including low-impact therapeutic exercises, guided self massage, myofascial release and fascial maneuvers, core and pelvic floor rehabilitation and function, cognitive flexibility, gait and balance, and more - all specific to your needs. Designed to help you combat pain, and leave feeling refreshed. Made for all fitness levels, but especially for beginners. If you're worried about pain, this is a space for you.

🟢 Register for Group Exercise Therapy & Personal Training Classes: Prepay each month for your sessions and receive a discounted rate. $35/session - $140 per month.

🟢 PRE-REGISTER: Commit to the next month of training - prepay for the month of your sessions and receive a discounted rate. $35/session - $140 per month.

🟠 Or Drop In - Group Exercise Therapy & Personal Training Class: Drop in rate $45 per class - Book a minimum 48 hours in advance.

Name: First & Last

Email

Date of Birth

If you have health concerns that may affect your safety during a class, please visit our health intake form. https://tally.so/r/68yaNe

If you have any questions, please email realigntherapyontario@gmail.com

Payment to Secure Your Spot

For payment, please send an Interac e-Transfer to realigntherapyontario@gmail.com for the total cost of all the events you wish to attend. Your spot(s) will be reserved by completed e-transfer.

📋 You're welcome to fill out an optional health intake form - It allows us to better tailor guidance throughout the session - or feel free to book a phone call by email.

Realign Therapy Health Intake Form 🌐 https://tally.so/r/68yaNe

Preparing for your session:

Please wear loose fitting clothing clothing that allows for full range of motion - including avoiding tight undergarments, restrictive/underwire bras, or compressive waistbands. Sessions are shoes off, and socks on. The practitioner may include manual assessments.

Looking forward to seeing you then!

Signature:

Your responses are confidential, encrypted in transit and at rest through a standard DPA, both GDPR and PIPEDA compliant. By executing this agreement, you acknowledge and assume all risks associated with your participation and agree to release, indemnify, and hold Micaela Hickman-Pearce, Realign & Associates harmless from and against any and all claims, liabilities, damages, losses, costs, and expenses, except where prohibited by law. Realign Therapy does not replace primary medical care. It is always safest to consult with your primary care provider before making lifestyle changes or beginning exercise.

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