Source On High Floatation Release Form printable pdf download

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: ___________________________

Source On High Floatation Release Form