"DANGER - ultraviolet radiation. Follow instructions.
As with natural sunlight, overexposure can cause eye injury and sunburn;
repeated exposure may cause premature aging of the skin and skin cancer.
Medications or cosmetics applied to the skin may increase your sensitivity
to ultraviolet light. Consult physician before using lamp if taking
any medications or if you believe yourself especially sensitive to
sunlight."
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"I have received and read the publication entitled
"Tanning Hazards" promulgated by the Rockland County Department of
Health prior to signing this consent, and have had an opportunity
to satisfactorily discuss my child's expected tanning treatments with
the operator of the facility.
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I hereby allow my child, ________________, to
utilize these tanning facilities for no more than ____ visits during
the month of _______, 2___.
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I understand that this consent will only be
valid for the month stated, and that I will be required to provide
continuing written consent on a monthly basis, for a specific number
of tanning sessions per month, so that I can monitor my child's exposure
to ultraviolet radiation.
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____________________
Signature of facility operator
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______________________
Signature of guardian
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____________________
Date
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______________________
Print name of guardian
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______________________
Print name of minor
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_____________________
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Age of Minor
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or
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The minor's parent or legal guardian is illiterate
and/or legally blind and I have read the publication entitled "Tanning
Hazards" promulgated by the Rockland County Department of Health and
the consent form aloud and in full to the parent or legal guardian
in the presence of the below signed witness.
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Signature of facility operator
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Witness
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Date
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