Tanning Facilities Parental Consent Form - New York State Department Of Health printable pdf download

New York State Department of Health

Tanning Facilities Parental Consent Form

Please read the following information and acknowledge that you

understand all warnings and accept all provisions by signing below.

ULTRAVIOLET RADIATION

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.

My minor child will not exceed the manufacturer’s maximum exposure time when using a tanning device.

ULTRAVIOLET RADIATION SENSITIVITY

A combination of UV radiation and certain foods, cosmetics or medications can increase sensitivity to UV radiation.

This is called “photosensitivity.”

I am aware that the use of UV radiation is not advised when eating certain foods or when using certain cosmetics

or medications. I will consult a physician before my minor child uses a tanning device if my minor child is using

photosensitive medications, has a history of skin problems or if I believe that my minor child is especially sensitive

to sunlight. I am aware that if my minor child does not tan in the sun, he or she is unlikely to tan from the use of a

tanning device.

TANNING HAZARDS INFORMATION SHEET

My minor child and I have read the New York State Department of Health Tanning Hazards Information Sheet.

PROTECTIVE EYEWEAR

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.

My minor child agrees to wear FDA certified protective eyewear.

PARENTAL CONSENT

I am the parent or legal guardian of a minor child who is seventeen (17) years of age.

Print the Name of Your Minor Child ______________________________ Date of Birth of Minor Child _________

My minor child and I have been given adequate instruction in the operation and use of tanning devices.

My minor child and I have read and understand the hazards of tanning so that I can make an informed judgment

about indoor tanning and the use of tanning devices.

I give consent for my minor child to use tanning devices in this facility.

Signature of Parent or Legal Guardian ___________________________________________ Date ____/____/____

Print the Name of Parent or Legal Guardian _________________________________________________________

Signature of Operator or Employee _____________________________________________ Date ____/____/____

Revised 07/12

Tanning Facilities Parental Consent Form - New York State Department Of Health