Tanning Facilities Parental Consent Form - New York State Department Of Health

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New York State Department of Health
Tanning Facilities Parental Consent Form
Please read the following information and acknowledge that you
understand all warnings and accept all provisions by signing below.
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.
My minor child 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 my minor child uses a tanning device if my minor child is using
photosensitive medications, has a history of skin problems or if I believe that my minor child is especially sensitive
to sunlight. I am aware that if my minor child does not tan in the sun, he or she is unlikely to tan from the use of a
tanning device.
TANNING HAZARDS INFORMATION SHEET
My minor child and I have read 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.
My minor child agrees to wear FDA certified protective eyewear.
PARENTAL CONSENT
I am the parent or legal guardian of a minor child who is seventeen (17) years of age.
Print the Name of Your Minor Child ______________________________ Date of Birth of Minor Child _________
My minor child and I have been given adequate instruction in the operation and use of tanning devices.
My minor child and 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 give consent for my minor child to use tanning devices in this facility.
Signature of Parent or Legal Guardian ___________________________________________ Date ____/____/____
Print the Name of Parent or Legal Guardian _________________________________________________________
Signature of Operator or Employee _____________________________________________ Date ____/____/____
Revised 07/12

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