HomeMy WebLinkAbout2017 - Customer Consent and Warning Froms - TanningCUSTOMER CONSENT AND WARNING FORM
Tanning Facility Name: Planet Fitness South Yarmouth
Address: 17 long pond Drive South Yarmouth MA 02664
Customer Name: Agreement #
Address:
Birth Date: Age: _
Home phone #: Work or Cell phone #:
Fitzpatrick/Skin Type Rating 1 2 3 4 5 6
PLEASE READ THE FOLLOWING WARNING. BY SIGNING BELOW, YOU ACKNOLWEDGE THAT YOU HAVE
READ AND UNDERSTAND THE WARNING AND ACCEPT ALL PROVISIONS AND THAT YOU ARE USING
THE FACILITIES AT YOUR OWN RISK.
WE RESERVE THE RIGHT TO REFUSE SERVICE TO ANYONE, AT ANYTIME.
USE OF THIS FACILITY REQUIRES THAT YOU BE 18 YEARS OR OLDER.
WARNING
DANGER - ULTRAVIOLET RADIATION
1. Follow instructions.
2. Avoid too frequent or lengthy exposure. As with natural sunlight, exposure to a sunlamp may cause eye
and skin injury and allergic reaction. Repeated exposure may cause chronic damage characterized by
wrinkling, dryness, fragility, bruising of the skin and skin cancer.
3. Wear protective eyewear. FAILURE TO USE PROTECTIVE EYEWEAR MAY RESULT IN SEVERE BURNS
OR LONG TERM INJURY TO THE EYES.
4. Ultraviolet radiation from sunlamps aggravates the effects of sun. Do not sunbathe before or after
exposure to ultraviolet radiation.
5. Abnormal or increased skin sensitivity or burning may be caused by certain foods, cosmetics or
medications, including but not limited to, tranquilizers, diuretics, antibiotics, high blood pressure
medication, birth control pills and skin creams. Consult a physician before using a sunlamp if you are
using medication, have a history of skin problems, or believe you are especially sensitive to sunlight.
Pregnant women or women on birth control pills who use a tanning device may develop discolored skin.
6. IF YOU DO NOT TAN IN THE SUN YOU WILL NOT TAN FROM USE OF THIS DEVICE. Use of a tanning
device does not provide a substantial protective base against the effects of the sun.
I acknowledge that I have read and understand the above Warning and I understand that I am using the
tanning facilities at my own risk.
Date
Customer Signature:
For illiterate or visually handicapped persons, the above "Warning" and the contents of this consent form
have been read to the customer in my presence.
Tanning Waiver and Warning
Follow instructions. Avoid Overexposure. WARNING: As with natural sunlight overexposure can cause premature aging of the skin and skin cancer. Wear
protective eyewear. FAILURE TO WEAR PROTECTIVE EYEWEAR MAY RESULT IN SEVERE BURNS OR LONG TERM INJURY TO THE EYES. Medications or cosmetics
may increase your sensitivity to the ultraviolet radiation. Consult physician before using tanning equipment. If you are using medications or have a history of skin
problems or believe to be sensitive to sunlight we recommend you do not use the tanning equipment. If you do not tan from the sun you are not likely to tan
from this product.
If yes call a pharmacist, prescribing doctor or poison control office to see if medication is photosensitizing.
2. Do you freckle or peel when tanning? Yes / No
3. Have you ever developed a rash, blister, an allergic reaction or sun poison? Yes / No
4. Are you currently pregnant? If so do you have you doctor's permission to tan? Yes / No
5. Are you under a doctor's care presently? Please list conditions. Yes / No
6. Do you presently or ever had cataracts (CE)? Yes / No
7. Have you ever been diagnosed with skin cancer? Yes / No
8. Do you wear contact lenses? Yes / No
9. Do you know how to wear protective eyewear? Yes / No
10. Have your tanned routinely in the last 30 days? Yes / No
11. Do you burn each time you go in the sun? Yes / No
12. Do you tan easily? Yes / No
RELEASE AND INDEMNIFICATION
1, (NAME OF PARTICIPENT) have chosen to use the tanning equipment
being offered by Planet Fitness, and I do fully and unconditionally agree to the following. 1) 1 am fully aware of, I fully accept and fully assume all
the risks of injury, illness and aggravation that are inherent in the use of tanning equipment. I represent to Planet Fitness that I have consulted with
my physician or other health authority regarding my intent to use the tanning equipment, and that I am physically capable of using such
equipment. 2)1 herby discharge, relinquish waive and release Planet Fitness and/or its officers, directors, agents, servants, volunteers, employees,
leaders, or other tanning participants, parent companies, subsidiaries and affiliates (all of whom are hereafter referred to as releases) from any and
all loss, damage, expense, injury, accident, delay and/or liability of any kind or nature whatsoever in connection with my use of the tanning
equipment. 3) 1 further indemnify, save, defend and hold harmless Planet Fitness and/or its releases from all claims actions and/or expenses which
might arise from any use of the tanning equipment. 4)1 hereby sign and deliver this release and indemnification to Planet Fitness to induce Planet
Fitness to permit my use of the tanning equipment, and I hereby acknowledge that such use is at my own risk and without representation of any
kind of having being made by Planet Fitness and/or its releases. 5) 1 do not suffer from any of the following; Albinism, actinic purigo, eczema, high
blood pressure, lung tuberculosis, melanoma, photo allergic eczema, porphyries, acne rosacea and/or any other condition which can be aggravated
by ultra violet light exposure. 6) 1 am not taking any medication that could make my skin extra sensitive to ultraviolet light. I do fully and
unconditionally agree to : always wear eye protection meeting FDA standards while tanning, use moisturizer in each eye prior to and immediately
following the use of tanning equipment, if I wear contacts, never tan indoors and/or outdoors twice in a 24 hour period, report all skin changes to a
family physician or other health authority for evaluation, Notify Planet Fitness when I change any medications, tan my nude body parts only 1/3 of
the recommended exposure time during initial tanning visits, read and abide by all signs posted in the tanning rooms. All information on this form
is correct. I have also separately received and signed a Customer Consent Form and Warning, which is incorporated by reference.
I HAVE READ FULLY UNDERSTAND, AND FULLY AGREE TO COMPLY WITH ALL OF THE ABOVE.
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TANNING FACILITY OPERATORS: Prior to tanning, the following warning must be provided to all customers. Except for
those customers who have signed the warning statement in the preceding six months, each customer must sign the
warning statement acknowledging they understand the warning. The warning statement must also be signed by the
operator and, when possible, by a witness to verify the warning was provided. For customers who cannot read,
operators must read or otherwise communicate the warning statement in a language and form understandable by the
customer.
TANNING CUSTOMERS: Prior to tanning, you must review the following warning statement. Unless you have signed
this warning statement in the preceding six months, you must sign the warning to acknowledge you understand the
warning. This warning statement must also be signed by the tanning facility operator and, when possible, a witness to
verify the warning was provided.
DANGER - ULTRAVIOLET RADIATION
1. Follow instructions.
2. Avoid too frequent or lengthy exposure. As with natural sunlight, exposure to a sunlamp may cause eye and
skin injury and allergic reaction. Repeated exposure may cause chronic damage characterized by wrinkling,
dryness, fragility, bruising of the skin and skin cancer.
3. Wear protective eyewear. FAILURE TO USE PROTECTIVE EYEWEAR MAY RESULT IN SEVERE
BURNS OR LONG TERM INJURY TO THE EYES.
4. Ultraviolet radiation from sunlamps aggravates the effects of sun. Do not sunbathe before or after exposure
to ultraviolet radiation.
5. Abnormal or increased skin sensitivity or burning may be caused by certain foods, cosmetics or
medications, including but not limited to, tranquilizers, diuretics, antibiotics, high blood pressure
medication, birth control pills and skin creams. Consult a physician before using a sunlamp if you are using
medication, have a history of skin problems, or believe you are especially sensitive to sunlight. Pregnant
women or women on birth control pills who use a tanning device may develop discolored skin.
6. IF YOU DO NOT TAN IN THE SUN YOU WILL NOT TAN FROM USE OF THIS DEVICE. Use of a
tanning device does not provide a substantial protective base against the effects of the sun.
Customer Signature
Tanning Facility Operator Signature
Witness Signature
Date
Date
Date
105 CM 123.000: TANNING FACILITIES 2017