Waiver – MamaCore Method

Welcome to MamaCore!

YOU are the reason this class was created, and because of that I want to make sure I know a few key things about you before we begin our time together. We are all in different stages of the motherhood journey, this questionnaire was created to give me (Kate) a better understanding of where you are on your journey and what I can do to best support you.

Waiver Form

First Name

Last Name

Where are you on the "motherhood spectrum"? This means: # pregnancies, # births, # months or years postpartum from your youngest baby. *Please feel free to share any additional information you feel is important for me to know around this topic. **Please also know that you only have to share what you feel comfortable sharing.

Do you have any injuries, or areas of concern, that I should know about? If so, please tell me as much as you are willing to share.

Is there a physical task or exercise that you currently can not do because you feel pain, or you feel you are not strong enough to perform it?

What would you like to get/achieve from taking this class?

Is there anything else you want me (Kate) to know before we get started?

I give Dr. Kate Antoniotti permission to view the information I share here. I understand that this information is pertaining to my chosen participation in MamaCore Semester Class held at the Center for Psychotherapy and Wellness.

I affirm that I alone am responsible to decide whether to practice MamaCore and participation is at my own risk. I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against MamaCore, LLC and its instructors.

I have been cleared to participate in exercise by my birth provider.

Yes!

Not yet

I give permission for MamaCore to capture photo and video during sessions for future marketing tools (including website and social media)

Accept Permission

Do Not Accept Permission