Meet The Team
Meet The Team
A cooperative healing arts and movement studio.
Float Tank Release Form
Emergency Contact Name
Emergency Contact #
To ensure a comfortable, clean, safe floatation experience, I agree to the following (by checking the box, you are legally acknowleding the following information to be true):
I am nor under the influence of any medication, drug, or alcohol
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
Are you under the care of a physician or other health care provider for a specific condition?
*If yes, please describe
Do you take any medication (including aspirin or ibuprofen)?
If yes, please list medication, dosage, and condition:
Please check if you have or have had any of the following:
skin problems or allergies
high/low blood pressure
varicose veins, blood clots, or any other circulatory problem
infectious or contagious disease
any needs that require special attention
any other medical conditions that we should be aware of before your float
None of the above
If you answered yes to any of the previous items, please describe:
*Otherwise type n/a
I understand that the Floatation Tank uses:
Pharmaceutical grade Epsom salts
Ultraviolet sterilization system
Natural enzymes and non-toxic biodegradable cleaning products
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 electronically signing this agreement voluntarily and recognize that my e-signature serves as complete and unconditional release of all liability to the greatest extent allowed by law in the State of Kentucky. Please type the following sentence, print and sign your name below: "I have read in its entirety and fully understand this Floatation Release Form"