THE YONGE & ST CLAIR TANNING SPA WAIVER FORM

www.stclairtanningspa.com 416-923-2411

13A St. Clair Avenue West, Toronto, Ontario M4V-1K6

FIRST NAME*

MIDDLE INITIAL

LAST NAME*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

DATE OF BIRTH*

Date

Email*

example@example.com

CELL PHONE *

HOME PHONE*

Please enter a valid phone number.

HOW DID YOU HEAR ABOUT US?

The following questions are necessary so that we may better serve you. Questions must be answered truthfully.

Do you Tan Easily*

Do you have regular exposure to the sun? *

Do you have a tendency to burn?*

Do you use tanning devices frequently/constant?*

Do you have any known allergies to the sunlight? *

Have you ever suffered severe sunburn? If so, when?*

Have you consulted a physician prior to using a tanning device? *

Have you ever been advised by a physician to stay out of the sun? If so, for what reason?*

Are you taking any medications that would cause sensitivity to the sunlight? Please review list below: Tranquilizers, Antibiotics, Birth control medications, High blood pressure medications, Diuretics, Other Photosensitizing Agents, and Cosmetics (due to the presence of eosin, psoralens, or antimicrobial agents)*

Do you have any allergies we should be aware of? For example: Latex, Dihydroxyacetone (DHA), fragrances etc:*

ACKNOWLEDGEMENT OF RISK AND RELEASE OF LIABILITY FORM

THIS AGREEMENT WILL AFFECT YOUR LEGAL RIGHTS. READ IT CAREFULLY

Name*

First NameLast Name

1. I agree to use eye protection each time I use the tanning device. I am aware that if eye protection is not used, eye damage can occur.*

2. I am aware that there are risks involved with using a tanning device, including but not limited to sunburns, eye damage, skin damage, skin cancer and premature skin aging ("Risks"). I freely accept and fully assume all responsibility for all Risks and possibilities of personal injury, death, or loss resulting from my use of tanning devices.*

3. I and my heirs, next of kin, executors, administrators and assigns (my “Legal Representatives”) agree: A) to waive all claims that I have or may have in the future against The Yonge & St. Clair Tanning Spa, its directors, officers, employees, volunteers, business operators, agents and site property owners or lessees (the “Company”); B) to release and forever discharge the Company from all liabilities for personal injury, death, property damage or loss resulting from my use of tanning devices, included but not limited to negligence, breach of any duty imposed by law, breach of contract or mistake or error in judgment of the Company; C) that the Company is not liable or responsible for damage to, loss or theft of any property; and D) to be liable for and to hold harmless and indemnify the Company from all actions, proceedings, claims, damages, costs demands, including court costs on a solicitor and own client basis, and liabilities of whatsoever nature or kinds arising out of or in any way connected with my use of tanning facilities. *

4. I confirm that I have reached the age of majority in the province in which I am using tanning facilities.*

5. I confirm that I have had sufficient time to read and understand this waiver in its entirety. I understand this agreement represents the entire agreement between myself and the Company, and is binding on myself and my legal Representatives.*

Signature*

Date*

Date

THE YONGE & ST CLAIR TANNING SPA

ACKNOWLEDGEMENT OF RISK AND RELEASE OF LIABILITY