Tanning Membership Form

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Birth Date

Home Tel.

Bus. Tel.

Please answer the following questions to the best of your ability.

The following questions are necessary, so we may better serve you. Each question must be answered HONESTLY.

Do you tan easily?

Do you regularly go in the sun?

Do you have a tendency to burn?

Do you have any known allergies to sunlight?

Have you ever suffered a major sunburn?

Have you ever been advised by a physician to stay out of the sun?

If so, what was the reason?

Are you taking any medication that would cause sensitivity to sunlight? (Please review the list below)

Antimicrobial Agents
Tetracyclines, espec. Demeolocycline
Sulfonamides, espec. Sulfanilamide
Griseofulvin
Halogenated salicylanilides)

Other Drugs
Phenothiazines, espec. Chlorpomazine
Thiazides
Psoralens
Sulfonylureas

Others
Oral Contraceptives, Sunscreens, Tar.
Cosmetics (due to presence of eosin, psoralens, or antimicronial agents)
*not included but limited to

Precautions are necessary for safe tanning. I agree that I will comply with all instructions on the use of the UVA tanning system, and that I am using these services at my own risk, and protecting my vision by using protective eyewear.

We, and our employees and agents, are not liable for any injury to person or property caused in any way by the use of its services or its premises. Also, they are not liable for the loss or theft of any personal property. Each person is responsible for safeguarding his or her own property.

If under legal age, parent or guardian must also sign consenting to the above.

First Name

Last Name

Date