VibraSound and Sensorium

SESSION RELEASE AND WAIVER FORM

 

The VibraSound SENSORIUM incorporates light, sound, color, aroma, and vibration to create a state of mind called "Sensory Resonance". This relaxed state of mind is thought to encourage freedom of thought, expand awareness, improve creativity, and provide a safe alternative to addictive behavior through the stimulation of numerous brain centers. This technology is not approved of or disapproved of by any governmental or other regulatory agency.

WARNING: INDIVIDUALS WITH PHOTOSENSITIVE EPILEPSY OR OTHER NERVE CONDITIONS SENSITIVE TO FLICKERING LIGHT SHOULD NOT USE THE SENSORIUM BECAUSE A SEIZURE MAY OCCUR. INDIVIDUALS WHO HAVE NEVER SUFFERED AN EPILEPTIC SEIZURE MAY NEVERTHELESS HAVE AN UNDETECTED EPILEPTIC CONDITION. IF YOU ARE NOT WILLING TO TAKE THIS RISK DO NOT USE THE SENSORIUM. IF YOU HAVE A PERSONAL OR FAMILY HISTORY OF EPILEPSY OR ANY OTHER CONDITION SENSITIVE TO FLICKERING LIGHT, ARE UNCOMFORTABLE WITH BRIGHT LIGHT, HAVE A HEART CONDITION, OR ARE UNDER THE RESTRICTIVE CARE OF A PHYSICIAN FOR ANY SERIOUS MEDICAL CONDITION, YOU SHOULD CONSULT A QUALIFIED MEDICAL PROFESSIONAL BEFORE USING THE SENSORIUM. IMMEDIATELY DISCONTINUE USE OF THE SENSORIUM IF YOU EXPERIENCE ANY OF THE FOLLOWING SYMPTOMS: INVOLUNTARY MOVEMENTS, DISORIENTATION, EYE OR MUSCLE TWITCHING, CONFUSION, DIZZINESS, CONVULSIONS OR NAUSEA.

In exchange for the right to use the VibraSound SENSORIUM the undersigned states the following:

 

1. I am 16 years of age or older or, if under the age of 18, my parent or guardian has indicated his

or her approval by signing below.

2. I am not under the influence of alcohol or drugs.

3. I am not using a cardiac pacemaker, nor am I suffering from any cardiac or heart disorder.

4. I do not have any serious eye disorder.

5. I am not currently, nor have I been during the past year, under the care of a physician for any

serious mental or physical illness or neurological disorder, nor am I under restrictive care due

to pregnancy, nor in the first trimester of pregnancy.

6. I have never suffered any serious injury, such as a concussion, to the head.

7. I do not have any history of epilepsy or other nerve disorder sensitive to flashing light.

8. I am willing to take responsibility for the slight chance that I may have a seizure.

8. I have read and understand the warnings set forth above.

 

Further, I agree to release and hold harmless Microfirm, Inc., InnerSense, Inc., Aha! Spa, VibraSound, and their owners, agents, employees, and assigns from all claims, damages, or other liabilities, present or future, whether or not known or anticipated, that may result from or arise out of the undersigned's use or intended use of the VibraSound, SENSORIUM or any of the other equipment at any company facility. The undersigned has read and understands the foregoing waiver of liability. (If the participant is under the age of 18, the undersigned parent or guardian hereby consents and agrees to be bound by this release.

 

Name (Print)___________________________________________________________________

 

Address: ______________________________________________________________________

Street City State ZIP

 

Date of Birth: ____________________________ Signature: ___________________________

 

Parent/Guardian Signature for participants under the age of 16: ___________________________