POLE WORX
1225 Union Ave
Kansas City, MO 64101
816.221.9679
APPLICATION AND WAIVER
-------------------- Please Read Carefully --------------------
Consent to use of the tanning facilities is
conditional upon provision of accurate answers to the following
questions and signing of the Waiver of Liability.
NAME: ________________________________________ _______
DATE OF BIRTH: ______________________
ADDRESS: _______________________________ CITY:
________________ How did you hear about us? _______________
PHONE: ______________________ EMAIL (optional):
________________________________________ _
QUESTIONS:
1. Do you tan easily? Yes o No o
2. Do you go regularly into the sun? Yes o No o
3. Do you have a tendency to burn? Yes o No o
4. Do you have any know allergies to sunlight? Yes o
No o
5. Have you ever suffered from a major sunburn? Yes o
No o
6. Have you ever been advised by a Physician to stay
out of the sun? Yes o No o
7. If so, for what reason?
________________________________________ __________________________
8. Are you taking any Medications that would cause
sensitivity to sunlight? Yes o No o
Please review the following list:
Antimicrobial Agent: Tetracyclines, espec
Demeolocycline, Sulfonamides, espec Sulfanilamide, Griseofulvin,
Halogenated salicylanilides.
Other drugs: Penothiazines, espec Chlorpromazine,
Thiazides, PSORALENS, Sulfonylures. Others: Oral Contraceptives,
Sunscreens, Tar,
Cosmetics (due to presence of eosin, psoralens, or
antimicrobial agents.)
Precautions are necessary for safe tanning. I agree
that I will comply with all the instructions on the use of the system
and that I am using these services at my own risk, and protecting my
vision by using the goggles provided.
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.
In consideration of the acceptance of the Application
and Waiver, I hereby waive and release for myself and by heirs,
executors, and administrators any claims of any nature whatsoever
which I might at any time have against the Company or employees and
acknowledge that I will use the services provided at my own risk. I
confirm that I have given accurate answers to the above questions,
that I will carefully follow all directions given and that I am over
the age of eighteen (18) years.*
Other things you should know:
1. Your session times are determined according to your
skin type, tanning history as well as the condition of OUR tanning
lamps and not by the maximum exposure times of the tanning units. We
realize that you may have been tanning elsewhere, but we know our
equipment the best, please follow our advice. Failure to follow said
advice may result in burning for which we can not be held responsible.
2. In order to accurately compile Client histories. We
are not able to allow others to use sessions that are on your
"screen". Each person wishing to tan must sign a Waiver and
be entered into our computer program individually.
3. For your safety and to prevent equipment damage,
please follow the instructions regarding the bed acrylics posted in
your tanning room.
4. We promote responsible tanning and do not allow
double sessions or tanning more than once per day.
5. Please try to be early for your appointments, we
may not be able to honour your appointment if you are late. Missing
two (2) appointments may result in the loss of one (1) of your sessions.
6. Mineral oil, baby oil, outdoor tanning oils and
lotions, etc. are harmful to the tanning bed acrylics. Please do not
use any lotion that is not intended for indoor use and/or that has
not been approved by one of our Tanning Consultants. Unapproved
lotions include Deep Tan, Panama Jack, Banana Boat and Tan2 Max.
Using these items may result in the loss of your tanning sessions
without notice.
7. To prevent unauthorized use of tanning packages,
client photos are taken and will appear only on your client screen.
8. If you ever have any questions, comments or
concerns, please let us know!
SIGNATURE: ________________________________________ _____ DATE: _____________________________