Tanning Facility Statement of Acknowledgement Form

• The Tanning Facility Statement of Acknowledgement Form is available in both English and Spanish in Portable Document Format (PDF).

Ultraviolet Radiation

Ultraviolet (UV) radiation is a human carcinogen and can cause skin cancer. Overexposure to UV radiation from tanning devices can cause burns and injury to the skin and eyes, premature aging of the skin and allergic reactions. Overexposure to UV radiation can reduce immunity, making your body less able to fight infection. It can also worsen existing medical conditions.

I will not exceed the manufacturer's maximum exposure time when using a tanning device.

Ultraviolet Radiation Sensitivity

A combination of UV radiation and certain foods, cosmetics or medications can increase sensitivity to UV radiation. This is called "photosensitivity."

I am aware that the use of UV radiation is not advised when eating certain foods or when using certain cosmetics or medications. I will consult a physician before using a tanning device if I am using photosensitive medications, have a history of skin problems or if I believe I am especially sensitive to sunlight. I am aware that if I do not tan in the sun, I am unlikely to tan from the use of a tanning device.

Tanning Hazards Information Sheet

I have been given a copy of the New York State Department of Health Tanning Hazards Information Sheet.

Protective Eyewear

Failure to use Food and Drug Administration (FDA) certified protective eyewear can result in severe burns or injury to the eye, such as photokeratitis, cataracts, macular degeneration and melanoma.

I agree to wear FDA certified protective eyewear.

Statement of Acknowledgement

I have been given adequate instruction in the operation and use of tanning devices.

I have read and understand the hazards of tanning so that I can make an informed judgment about indoor tanning and the use of tanning devices.

I verify that I am 18 years of age or older.

Signature of Patron _________________________________________________________________ Date _____/_____/_____

Print the Name of Patron __________________________________________________________________________________

Type of Patron Identification _______________________________________________________________________________

Signature of Operator or Employee Signature _____________________________________________ Date _____/_____/_____