Disclosures and Waivers

CLOUD NINE FLOTATION SAFETY COMPLIANCE and LIABILITY WAIVER AGREEMENT

Name:____________________________________________________Age:____DOB:___/___/________

Address:______________________________________________________________________________

Cell Phone:___________________________________Email:____________________________________

Emergency Contact Name:_______________________________________Phone:__________________

We make every reasonable effort to provide and ensure a comfortable, clean and safe floating environment for you and ask that you comply with all of our directives and procedures. Please read and initial each of the follow statements of this agreement and sign below.

____ I do not have any communicable or infectious disease, illness, open sores, or skin disorders.

____ I do not have freshly dyed (colored) hair (when I shower the water runs clear).

____ I am not menstruating.

____ I am not under the influence of drugs or alcohol or non-prescribed medication.

____ I do not have a condition where I am receiving medication that may be adversely affected by deep                       relaxation and/or immersion in Epson salt solution.

____ I do not have untreated high (>+180/120) or low (<-90/50) blood pressure.

____ I am not diabetic with insulin dependency, or I have medical authorization to float.

____ I do not have chronic heart or kidney disease. If I do, I have medical authorization to float.

____ I do not suffer from seizures or epilepsy. If I do, I have medical authorization to float.

____ I do not have claustrophobia. If I do, I have medical authorization to float.

____ I am at least 18 years of age or have guardian with me to sign waiver.

____ I have secured written permission to float from my physician if I am pregnant.

Cloud Nine uses:

35% hydrogen peroxide (H202)

Ultraviolet (UV) sterilization systems

Natural enzymes, botanical extracts and non-toxic biodegradable cleaning products.

____ I am not allergic or skin-sensitive to these products used as a sanitizing agent.

____ I will not float with oils or creams on my body, hair products, jewelry or contact lenses.

____ I feel well today, have no incontinence or nausea, and will only float when I feel well.

____ I have or will receive(d) an orientation, which familiarizes me with the safe and appropriate use of the                   tank. I understand that individual experiences with floating are varied and unique, and I take full                           responsibility for my thoughts and actions while in the flotation tank. This waiver of liability and all                       agreements made herein shall apply to each and every use of the tank.

____ I hereby agree to irrevocably hold harmless and waive any claims that I now may have or may have                     hereafter again Kalyn Wolf Consulting LLC DBA Cloud Nine Flotation, its owner, employees, agents and             dependents.

____ I have read and fully understand and agree to the above terms of this Liability Waiver Agreement. I am                signing this agreement voluntarily and recognize that my signature serves as complete and unconditional          release of all liability in connection with the use of the flotation tank and facilities, including the entire                  interior of the premises operated as Cloud Nine Flotation, its agents and all employees, whether such loss          or damage be it direct or indirect.

____ I understand that if I do something that causes damage to the Cloud Nine Flotation Tank, or its contents, I          am financially responsible.

____ Any actions that require Cloud Nine Flotation to replace the sensory deprivation tank solution will require a          $1,500 replacement fee to be paid by the client.

Printed Name:___________________________________________________________Date:__________

Signature:_____________________________________________________________________________