Name

First Name

Last Name

Phone Number

Email Address

Class Dates I am Attending

Wednesday July 23, 2025 2:30 - 5:30 PM PST

Sunday August 10, 2025 9:30 AM - 12:30 PM PST

Age

0-12

13-21

22-35

36-49

50-62

63-75

76-85

86-95

96+

How did you hear about Aston® Kinetics, and what brought you to request a session?

What is your occupation?

What would you like to focus on in your session with Judith Aston?

Posture, movement, efficiency, stress relief, athletic performance, etc.

Illnesses, surgeries and/or injuries history:

What have physicians and/or practitioners provided in terms of diagnosis or treatment?

Are you currently taking any medication?

What other kind of medical care or body disciplines are you currently involved in, if any, and with whom?

What is your occupation and what kind of activities do you perform while working, which seem to stress certain areas of your body?

System Requirements

Online movement coaching requires certain system requirements to use Zoom. Due to a high volume of scheduling inquiries, the appointment time you schedule begins 5 minutes after your scheduled time. This is for Judith to review your intake and photos to better assist you during the session. If there are technical difficulties during your session, we do not refund or allow for additional time. It is your responsibility to ensure that technical issues are resolved before your scheduled appointment. I understand these requirements and know that it is my responsibility to handle all technical difficulties prior to my appointment. I also understand that there will be no refunds, allotment of extra time or credits of any kind if my technology does not work during my online movement lesson.

Yes

Disclaimer

I understand that this Aston® movement session is not a teacher training class: it is for my personal use only. I understand that Aston® Kinetics cannot be responsible for instructing others in this content shared during this session. I understand that the Aston® Kinetics program is not a substitute for medical treatment. I take responsibility for my body and my participation in this session. I release the Aston Paradigm Corporation and its agents from all rights and claims with respect to this session.

Yes

Signature

Please type your full name

Thank you! We will get back to you on some appointment suggestions. Please submit 4 photos of yourself so that Judith can review them prior to your appointment so as to better assist you in the session and maximize the time you get to spend with her. Please click here to submit your photos directly to our Drop Box account. Or you can copy and paste the link below in your web browser

In the meantime, if you have questions please contact us at office@astonkinetics.com

Licensed Practitioners CEU’s- Intake Form

Please complete all fields on this form
and submit before July 16, 2025.

Upon submission, You will be redirected to a folder in our dropbox where you can submit 4 photos of your postural alignment. These photos will help Judith Aston design these classes to meet the needs of all participants.

Aston Kinetics

P.O. Box 3568 Incline Village, NV 89450 | 775.831.8228 | office@astonkinetics.com

We are a Proud member and provider with these organizations

Licensed Practitioners CEU’s- Intake Form

Please complete all fields on this formand submit before July 16, 2025.

Upon submission, You will be redirected to a folder in our dropbox where you can submit 4 photos of your postural alignment. These photos will help Judith Aston design these classes to meet the needs of all participants.

Please complete all fields on this form
and submit before July 16, 2025.