WONDER BEACH

Tanning Facility Statement of Acknowledgement Form

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

Ultraviolet (UV) radiation is a human carcinogen and can cause skin cancer. Overexposure to UV radiation from tanning devices can cause burns and injury to the skin and eyes, premature aging of the skin and allergic reactions. Overexposure to UV radiation can reduce immunity, making your body less able to fight infection. It can also worsen existing medical conditions. / will not exceed the manufacturer's maximum exposure time when using a tanning

Ultraviolet Radiation Sensitivity

A combination of UV radiation and certain foods, cosmetics or medications can increase sensitivity to UV radiation. This is called "photosensitivity." / am aware that the use of UV radiation is not advised when eating certain foods or when using certain cosmetics or medications. / will consult a physician before using a tanning device if / am using photosensitive medications, have a history of skin problems or if / believe / am especially sensitive to sunlight. / am aware that if / do not tan in the sun, / am unlikely to tan from the use of a tanning device.

Tanning Hazards Information Sheet

/ have been given a copy of the New York State Department of Health Tanning Hazards

Failure to use Food and Drug Administration (FDA) certified protective eyewear can result in severe burns or injury to the eye, such as photokeratitis, cataracts, macular degeneration and melanoma. / agree to wear FDA certified protective eyewear.

/ have been given adequate instruction in the operation and use of tanning devices. / have read and understand the hazards of tanning so that / can make an informed judgment about indoor tanning and the use of tanning devices. / verify that / am 18 years of age or older. Signature of Patron

Signature of Patron

Print Name of Patron

First NameLast Name

Type of Patron Identification

Date Signed

Date

Wonder Beach Dumbo 117 Adams Street, Brooklyn, NY 11201 Tel. 929-969-7607

Wonder Beach Dumbo Release Form

Name

First NameLast Name

Client's Date of Birth

Date of Birth

Email

example@example.com

Client's Phone Number

Address

What is your skin type?

What is your skin color?

Have you had any tanning within 6 months?

Do you have any allergies?

Are you Pregnant? or Breastfeeding?

Did you dye you hair within the last 3 months?

Do you have any respiratory ailment?

Do you have any cardiovascular ailment?

Do you have high-blood pressure or hypertension?

Have you had any surgery within 6 months?

Did you undergo any skin treatment inside a clinic before?

Consent

I understand the risk of indoor tanning to my skin and overall health. Wearing protective eyewear is a requirement. I understand that the employees here are trained and skilled to do their tasks and I should comply with the Tanning Salon's policy and procedure. Wonder Beach Dumbo will require me to wear protective glasses during the procedure. I hereby absolve Wonder Beach Dumbo Tanning salon of any liabilities, claims, any lawsuit from my side for I was forewarned of the risk of indoor tanning to my skin and overall health. Wonder Beach Dumbo also affirmed the harmful effects of overexposure to ultraviolet radiation emitted by the tanning device may cause skin burns, premature skin aging, melanoma, and skin cancer. Client Signature

Client's Signature

Date Signed

Date