Fill and Sign the Agreement Release Form

AGREEMENT AND RELEASE FORM FOR TANNING FACILITY USE NOTICE TO THE COMSUMER: DO NOT SIGN THIS CONTRACT UNTIL YOU HAVE READ ALL OF IT. ALSO, DO NOT SIGN THIS CONTRACT IF IT CONTAINS ANY BLANK SPACES. This Agreement is made and entered into this the ____day of ___________, 2000 by and between _____________________________________________(hereinafter “Company”) and ________________________________________(hereinafter “Customer”) and is subject to the following terms and conditions: 1. Non-transferable. Customer agrees that the rights granted to Customer hereunder may not be transferred, assigned or conveyed to any other person. 2. Term. The term of this Agreement shall extend for a period of _______ months beginning on the ______ day of ____________, 20__ . This agreement shall automatically be extended on a monthly basis unless terminated by Customer or Company. After the initial term, this agreement may be cancelled by Customer or Company upon 30 days notice. 3. Consideration. In full consideration of a monthly payment of $_____________by Customer and subject to the other terms and conditions of this Agreement, Company shall provide access and allow unlimited visits by Customer to use the tanning facilities operated by Company at ____________________________________________,____________, Mississippi. 4. Independent Advice. Customer represents and warrants that he/she has been advised that exposure to tanning devices carries certain health risks and potential side effects. Customer further represents and warrants that he/she has had the opportunity to seek independent medical or other advice about the risks associated with indoor suntanning and exposure to tanning devices prior to signing this Agreement. 5. Release and Indemnity. Customer hereby releases, discharges and indemnifies Company, its successors, agents, assigns, employees and representatives from any and all claims, demands, damages, actions or suits of any kind whatsoever and including but not limited to the causation, exacerbation or increase in risk of any adverse health condition, whether known or unknown, as a direct or indirect result of Customer’s use of tanning equipment and facilities furnished by Company. 6. Rules and Regulations. Customers agrees to abide by all rules and regulations that may from time to time by adopted by Company governing the use of the tanning facilities of Company. 7. Entirety. This instrument supersedes any prior negotiations, discussions or agreements and sets forth the entire agreement between the parties with respect to this subject matter. No modification shall be binding unless confirmed by a written instrument signed by both parties. 8. Applicable Law. The parties hereto agree that this Agreement is to be enforced and construed according to the laws of the State of Mississippi and, in the event that any - 1 - portion of this Agreement is set aside by a court of competent jurisdiction, the balance shall remain in full force and effect to the extent feasible. 9. Cancellation. IF WITHIN FIVE(5) BUSINESS DAYS YOU DECIDE YOU DO NOT WISH TO REMAIN A MEMBER OF THIS HEALTH SPA, YOU MAY CANCEL THIS AGREEMENT BY MAILING A NOTICE TO THE HEALTH SPA BY MIDNIGHT OF THE FIFTH BUSINESS DAY FOLLOWING YOUR PURCHASE OF THE CONTRACT STATING YOUR DESIRE TO CANCEL THIS CONTRACT. THE WRITTEN NOTICE SHOULD BE MAILED TO THE FOLLOWING ADDRESS: ______________________________ ______________________________ ______________________________ ______________________________ 10. Disability or Death, If, by reason or death or disability, Customer is unable to use the facilities of Company, Customer and his or her estate shall be relieved of the obligation of making payments for such services other than those received prior to death or the onset of the disability. If Customer has prepaid any sum for health spa services, the unexpired portion shall be promptly refunded to Customer or his or her representative. WITNESS OUR SIGNATURES, the day and date first above written. Company Customer ______________________ ___________________________ - 2 - Customer Information Name: ___________________________ Social Security Number: _________________ Address: _________________________ _________________________________ _________________________________ Home Phone: _____________________ Work Phone: ______________________ Employer Name and Address: _________________________________ _________________________________ _________________________________ _________________________________ In case of Emergency call: ____________________________________ ____________________________________ ____________________________________ Relationship: _________________________ Date: _________________ Signature: ___________________________ - 3 -