Source on High Floatation Release Form
Name: _______________________________________
Age: __________
Birth Date: ____ / ____ / ____
Address: ______________________________________
City: _____________________________
Zip: ______________________________
Phone: ___________________________
Email: ____________________________
Emergency Contact Name: _______________________
Emergency Contact Phone: _______________________
To ensure a comfortable, clean and safe floatation experience, I agree to the following (please initial each statement):
____l do not have any communicable or infectious disease, illness, or skin disorder
____I do not have a condition or am medicated in any manner which may be adversely affected by profound relaxation and/or
immersion in concentrated magnesium sulfate (Epsom salt) water Solution
____I am not under the influence of any medication, drug or alcohol
____ I do not have a history of high (>= 180/120) or low (<=90/50) blood pressure
____ I am not diabetic with an insulin dependency
____ I do not have kidney disease
____ I do not suffer from uncontrolled seizures or epilepsy
____ I am not currently menstruating
____ I have consulted with, and secured written permission from my physician to use the Floatation Tank if I am pregnant
I understand that the Floatation Tank uses:
• Pharmaceutical grade Epsom salts
• Ultraviolet sterilization system
• Natural enzymes and non-toxic biodegradable cleaning products
• Hydrogen peroxide
I further understand that each individual may have a unique experience. I have been given an orientation which familiarized me with the
safe and appropriate use of the tank. I agree to take full responsibility for my thoughts and actions while in the floatation tank and the
waiver of liability and all agreements made herein shall apply to each and every use of the floatation tank.
I hereby agree to irrevocably release and waive any claims that I have now or may have hereafter against Source on High and its
employees and agents. I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am signing
this agreement voluntarily and recognize that my signature serves as complete and unconditional release of all liability to the greatest
extent allowed by law in the State of Kentucky.
Please legibly write the following sentence in your own handwriting, print and sign your name below:
"I have read in its entirety and fully understand this Floatation Release Form"
X________________________________________________
Printed Name: ________________________________________
Date: ___________________________