Name: Email: Phone:


Date of birth: (Month / day / year): *

Emergency Contact: Phone:

By signing this hold harmless agreement and release of responsibility and assumption of risk, I confirm that I acknowledge there may be hereditary risks associated with the use of certain equipment, the use of spa facilities, participation in programs and / or spa treatments.

I recognize and accept that I am responsible for my own health; that Spa associates and / or technicians are not health professionals and cannot be expected to diagnose and / or treat individual health problems.

I understand that I am responsible for discussing any questions I may have about my health conditions (if any), during any program or treatment at the Spa and, if symptoms related to health occur, I will stop participating and inform the Spa staff about my symptoms.

In the event that you have reason to believe that medical authorization must be obtained before participating in any Spa treatment, therapies, steam, pool or equipment of the facility, I agree to consult a doctor first and obtain a written permission from a doctor before the start of any program, treatment or activity.

By choosing to receive treatments related to the Spa and / or participating in activities and programs related to the Spa, I guarantee that, to the best of my knowledge and understanding, I do not have any disability, condition or medical condition that prevents me from receiving such treatments and / or participating thereof.

Consequently, in the light of the foregoing agreement, I hereby release YOUR COMPANY NAME GOES HERE (and its parent corporation, subsidiaries, affiliated corporations, and their respective officers, directors, shareholders and employees) and waive each and every one of the claims, responsibilities, personal damages and/or injuries that I may experience directly or indirectly from receiving spa-related treatments, using its facilities and / or participating in the programs or activities offered by the spa.

I am age 18 (or legally age 18 today)


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