Please fill out this form completely and submit it online, or print it out and bring it with you to your first class. You will need to check the agreement box in order to submit.

Personal Information

Full Name (required)

Email (required)

Phone Number

Mailing Address

Additional comments

Terms and Conditions
  • If I am or will be pregnant during the course, I know that during and after pregnancy certain physiologic changes may occur in my body. I also understand that there is a low but inherent risk of vaginal bleeding, miscarriage, premature labor and premature birth with any pregnancy.
  • I have voluntarily registered to participate in a personal training session or Tupler Technique® session or program with Bonnie Wayne of Diastasis & Ab Re-Pair, CPT and a professional licensed provider the Tupler Technique® Program. In order to participate in this program, I must understand and sign this informed consent.
  • I accept full responsibility for participating in this program and agree to communicate any and all material physical discomforts or problems to my instructor. I accept all responsibility for my health and any resultant injury or mishap that may affect my well being while participating in the Tupler Technique® Program. In the event I suffer any injury or discomfort while participating in or resulting, directly or indirectly, from my participation in this program, I hereby waive any and all claims relating to such injury or discomfort against my instructor and any of their respective agents or affiliates.
  • The workshop Content and information I learn from Diastasis & Ab Re-Pair and Bonnie Wayne will be used for my own personal health improvement, and will not be used by me to teach to others for monetary compensation/profit or personal gain.

By checking this box I am agreeing to the terms and conditions listed here, and is therefore a binding contract.