Tanning Facility Statement of Acknowledgement

Please read the following information and acknowledge that you understand all warnings and accept all provisions by signing below.

Avoid Overexposure

As with natural sunlight, overexposure can cause eye and skin injury and allergic reactions. Repeated exposure may cause burns, premature aging of the skin and skin cancer. I will not exceed the manufacturer's maximum exposure times.

Ultraviolet Radiation Sensitivity

Certain medications or cosmetics or foods may increase your sensitivity to ultraviolet radiation.

I have been advised of conditions, such as the use of photosensitizing drugs, under which the use of ultraviolet radiation is contraindicated. I will consult a physician before using a sunlamp if using medications or have a history of skin problems or believe I am especially sensitive to sunlight. I am aware that if I do not tan in the sun, I am unlikely to tan from the use of a tanning device.

Protective Eyewear

Failure to use FDA certified protective eyewear may result in severe burns or long-term injury to the eye. I agree to wear protective eyewear.

Information Sheet

I have been given a copy of the New York State Department of Health information sheet.

Acknowledgement

I have been given adequate instruction in the operation of tanning devices.

I have read and understand the contents of this form.

I verify that I am 18 years of age or older.

Patron signature ____________________________________ Date ____________

Print name of patron _________________________________________________

Type of identification ________________________________________________

Operator or Designee signature ________________________ Date ____________