Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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Date of Birth *

MM

DD

YYYY

Please Select one of the following categories that best fits your skin condition: *

Always burn and never tan

Burn most of the time and occasionally tan

Achieve a tan most of the time

Always tan and never burn

Check all that apply

I have tanned in the past and I tan easy

I am under medical care for your skin

I am allergic to the sun

I always have dry skin

I am presently taking medication that could cause sensitivity to the sun

I am pregnant

I wear contacts

By signing this waiver, I agree to above terms and conditions

Signed

First Name

Last Name

Date *

MM

DD

YYYY