Moving to Heal: Registration

It is great that you've taken the first step to register for this course. Please take some time to fill in this registration. Much of this information and declaration is mandatory before joining any exercise course. The information will also aid us when helping you take care of your needs in the Moving to Heal group exercise class.

Any field below that has a * requires an answer.

Personal details
Who is your emergency contact?
What is your emergency contact's phone number?
Medical history and current state of health
Please select any areas that may affect your ability to take this class.
Medication and/or substances
Your Nia experience
Participation waiver and medical release statement

My participation in these classes is voluntary and at my own risk.

  • I take responsibility for any activity I participate in provided by Plensory Movement, Stephanie DeMay, and any teachers and trainers associated with these classes.
  • I hereby release respective owners, teachers, and assigns associated with Plensory Movement, Moving to Heal teachers, and Nia Technique from any liability for any claims, demands, injuries, actions, or causes of actions to my person or property arising out of or connected with the use of any of the services, equipment, or facilities.
  • I further understand the activities may involve physically strenuous exercise and risk of bodily injury.
  • I understand that I am receiving dance fitness exercise for the purpose of using Nia Movement as a complementary treatment to support my physical, mental, emotional, and spiritual well being.
  • I understand that the teacher is NOT legally permitted to diagnose diseases or treat injuries, and that dance fitness exercise should NOT take the place of my doctor's care. I understand that I am fully in charge of what I do, and that I am encouraged to alter movement in order to feel more comfortable. I also understand that if the teacher feels unable to support my needs, I may be asked to find an alternative program that can effectively suit my needs.
  • I understand that the teacher reserves the right to refuse service to anyone, at any time, for any reason. Plensory Movement will NOT release your information without your written permission.
  • I accept full responsibility for any activity I engage in with Plensory Movement, Stephanie DeMay, Nia Technique, and any other teachers and trainers associated with these classes. I have carefully read with a full, definite,
    and clear understanding the foregoing provisions, and by submitting this form, I am stating that I have read, understand, and agree to all content written above in its entirety.

Hint: If nothing happens after you click "I accept", please check that you have filled out all the required fields (look for the *).