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SAFETY INSTRUCTIONS FOR WHOLE BODY CRYOTHERAPY

  1. YOU MUST WEAR COTTON OR WOOL SOCKS, GLOVES, RUBBER SOLED SLIPPERS, and SHORTS FOR MEN (These items are provided).
  2. TREATMENTS ARE LIMITED TO 3 MINUTES PER SESSION. OVEREXPOSURE TO THE COLD TEMPERATURES MAY CAUSE CHILBLAIN (Red chapped skin).
  3. DURING TREATMENT, YOU MUST AVOID INHALING THE NITROGEN FUMES; WHILE NON-TOXIC, THEY ARE DEVOID OF OXYGEN AND MAY CAUSE FAINTING (No ducking into the cabin).
  4. YOU MAY END THE PROCEDURE AT ANY TIME IF YOU EXPERIENCE ANY PROBLEMS OR ANXIETY.
  5. ABNORMAL SKIN SENSITIVITY TO COLD MAY BE CAUSED BY CERTAIN FOODS, COSMETICS, OR MEDICATION, INCLUDING BUT NOT LIMITED TO THE FOLLOWING: TRANQUILIZERS, HIGH BLOOD PRESSURE MEDICATION.
  6. A PERSON WHO IS LESS THAN 18 YEARS OF AGE MAY NOT USE WHOLE BODY CRYOTHERAPY WITHOUT PARENTAL/GUARDIAN CONSENT.
  7. YOU MUST BE IN VISUAL CONTACT WITH THE ALAMO CITY CRYOTHERAPY TECHNICIAN DURING THE SESSION.
  8. YOU MUST HAVE DRY SKIN WITHOUT RECENT APPLICATION OF LOTIONS AND/OR MOISTURIZERS.
  9. YOU MUST TAKE OFF ALL JEWELRY.

YOU CANNOT RECEIVE WHOLE BODY CRYOTHERAPY
IF ANY OF THESE CONDITIONS APPLY TO YOU:

  • PREGNANCY
  • FEVER
  • SEVERE HYPERTENSION (BP > 180/100)
  • TUMOR DISEASE
  • ACUTE OR RECENT MYOCARDIAL INFARCTION
  • ARRHYTHMIA
  • UNSTABLE ANGINA PECTORIS
  • SEVERE ANEMIA
  • SYMPTOMATIC LUNG DISORDERS
  • BLEEDING DISORDERS
  • SYMPTOMATIC CARDIOVASCULAR DISEASE
  • INFECTION
  • CARDIAC PACEMAKER
  • CLAUSTROPHOBIA
  • PERIPHERAL ARTERIAL OCCLUSIVE DISEASE
  • COLD ALLERGY
  • UNCONTROLLED SEIZURES
  • RAYNAUD’S SYNDROME
  • ACUTE OR RECENT CEREBROVASCULAR ACCIDENT
  • ACUTE URINARY TRACT DISEASES

POSSIBLE RISKS OF WHOLE BODY CRYOTHERAPY

FLUCTUATIONS IN BLOOD PRESSURE (DUE TO PERIPHERAL VASOCONSTRICTION, BLOOD PRESSURE MAY BRIEFLY INCREASE BY UP TO 10 POINTS SYSTOLICALLY DURING TREATMENT. THIS EFFECT SHOULD REVERSE AFTER THE END OF THE PROCEDURE, AS PERIPHERAL CIRCULATION RETURNS TO NORMAL), ALLERGIC REACTION TO EXTREME COLD (RARE), CLAUSTROPHOBIA, ANXIETY, ACTIVATION OF SOME VIRAL CONDITIONS (COLD SORES) ETC. DUE TO STIMULATION OF THE IMMUNE SYSTEM. ONE PRIMARY INHERENT RISK OF CRYOTHERAPY IS SKIN SENSITIVITY AND SKIN IRRITATION (RED CHAPPED SKIN). IT IS IMPOSSIBLE TO PREDICT HOW CLIENT’S SKIN WILL REACT DURING OR AFTER CRYOTHERAPY.

WHAT IS NORMATEC COMPRESSION THERAPY?

NORMATEC® - COMPRESSION THERAPY IS DYNAMIC COMPRESSION DEVICES DESIGNED TO ENHANCE BLOOD FLOW AND SPEED RECOVERY FOR THE ARMS/SHOULDERS, LOWER BACK/HIPS AND LEGS. NORMATEC’S PATENTED SEQUENTIAL PULSE TECHNOLOGY SETS IT APART FROM OTHER DISTINCT MASSAGE COMPRESSION DEVICES BY SYNERGISTICALLY COMBINING THREE DISTINCT MASSAGE TECHNIQUES – PULSING, GRADIENT HOLD AND DISTAL RELEASE.

YOU CANNOT RECEIVE NORMATEC COPRESSION THERAPY
IF ANY OF THESE CONDITIONS APPLY TO YOU:

  • VENOUS THROMBOSIS
  • FRACTURE OR BROKEN BONE
  • RECENT SURGERY
  • OPEN WOUNDS20

WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

  1. In consideration for using the cryo device (Equipment), I hereby RELEASE, WAIVE, DISCHARGE, and HOLD HARMLESS Evolution Cryotherapy and Wellness, LLC, its officers, servants, agents, employees and volunteers (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions and causes of action whatsoever arising out of or related to any loss, damage, or injury, that may be sustained by any person, while using the equipment or due to the use of the equipment.
     
  2. I hereby confirm that no warranty or guarantee, or other assurance, has been made to me covering the results of the cryo process, and I hereby relieve them and hold them harmless from all liabilities for injury or damage that may occur to me. I fully understand the administration of the process, including possible adverse reactions, side effects, or other possible complications. It is understood that this CONSENT is being given in advance of any administration of the process, and is being given by me voluntarily to use the Equipment of Evolution Cryotherapy and Wellness, LLC.
     
  3. I am fully aware of the risks and hazards connected with the use of the Equipment, including the risk of physical injury or disability as the result of such injury, and I am voluntarily participating in said Equipment usage, and entering the above named premises to engage in such usage. I VOLUNTARILY ASSUME FULL RESPONSIBILITY FOR ANY RISKS OF LOSS that may be sustained, or any loss or damage to property as a result of being engaged in such an activity.
     
  4. I further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage or costs that may incur due to the use of Equipment by me.
     
  5. It is my express intent that this Release and Hold Harmless Agreement shall bind the members of my family and spouse (if any), if I am alive, and my heirs, assignees and personal representative, if I am not alive, and shall be deemed as a RELEASE, WAIVER, AND DISCHARGE of the above named RELEASEES. I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be construed in accordance with the laws of the State of TEXAS.
     
  6. I understand that the RELEASEES will not be responsible for any medical costs associated with any injury.
     
  7. I understand that Whole Body Cryotherapy is provided for the basic purpose of relaxation, stress reduction, relief of muscular tension, and recovery from surgery, illness or injury. I further understand that Whole Body Cryotherapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment that I am aware of.
     
  8. I understand that Whole Body Cryotherapy therapists are not qualified to perform skeletal adjustments, diagnose and/or prescribe, and that nothing said in the course of the session should be construed as such.
     
  9. Because Whole Body Cryotherapy is contraindicated under certain conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand that there shall be no liability on the therapist’s part should I forget to do so.

MY SIGNATURE BELOW CONSTITUTES MY ACKNOWLEDGMENT THAT (1) I HAVE READ, UNDERSTAND, AND FULLY AGREE TO THE FOREGOING CONSENT, (2) THE PROPOSED INDOOR CRYO PROCESS HAS BEEN SATISFACTORILY EXPLAINED TO ME AND I HAVE ALL OF THE INFORMATION I DESIRE AND (3) I HEREBY GIVE MY AUTHORIZATION AND CONSENT. THIS CONSENT SHALL STAND AS LONG AS I USE THE EQUIPMENT AT THE LOCATION NOW AND IN THE FUTURE. I HAVE READ THE INSTRUCTIONS FOR PROPER USE OF THE FACILITIES AND DO SO AT MY OWN RISK AND HEREBY RELEASE THE OWNERS, OPERATORS, FRANCHISERS, OR MANUFACTURERS, FROM ANY DAMAGE OR HARM THAT I MIGHT INCUR DUE TO USE OF THE FACILITIES.

IN SIGNING THIS RELEASE, I ACKNOWLEDGE AND REPRESENT THAT I HAVE READ AND UNDERSTAND THE FOREGOING WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT, I AM AT LEAST EIGHTEEN (18) YEARS OF AGE AND FULLY COMPETENT; I HAVE GIVEN UP CONSIDERABLE FUTURE LEGAL RIGHTS; AND I EXECUTE THIS RELEASE FREELY, VOLUNTARILY, UNDER NO DURESS OR THREAT OF DURESS, WITHOUT INDUCEMENT, PROMISE OR GUARANTEE BEING COMMUNICATED TO ME. 

FURTHERMORE, I AGREE THAT I WILL COMPLY WITH ALL INSTRUCTIONS ON THE USE OF THE CRYO DEVICE AND THAT I AM USING THESE SERVICES AT MY OWN RISK. I AGREE TO USE ALL SESSIONS WITHIN THE TERMS OF THE CONTRACT DATES AND UNDERSTAND THAT REFUNDS ARE NOT GIVEN ON UNUSED PORTIONS OF PURCHASED PACKAGES.

Today's Date: October 21, 2019

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Information

IF YOU HAVE ANY OF THESE CONDITIONS, WE RECOMMEND YOU CHECK WITH YOUR DR. TO RECEIVE WHOLE BODY CRYOTHERAPY:

HIGH BLOOD PRESSURE
KIDNEY OR URINARY TRACT DISEASE
JOINT DISEASES
ANY HEART DISORDERS
STROKE
MIGRAINES
HEART ATTACK IN PREVIOUS 6 MONTHS
AREAS OF NUMBNESS
RESPIRATORY DISEASES
DIABETES
PARALYSIS

MEDICAL INFORMATION (LIST MEDICATIONS TAKING AND DOSES)
WHAT ARE YOU HOPING TO ACHIEVE? *
IMPROVE ATHLETIC PERFORMANCE
RECOVERY FROM INJURY, ILLNESS OR SURGERY
BEAUTY & WELLNESS
HOW DID YOU HEAR ABOUT US?*

If Other, please specify:
I GRANT ALAMO CITYCRYOTHERAPY, LLC FULL RIGHTS TO USE THE IMAGES RESULTING FROM THE PHOTOGRAPHY/VIDEO FILMING, AND ANY REPRODUCTIONS OR ADAPTATIONS OF THE IMAGES FOR FUNDRAISING, PUBLICITY OR OTHER PURPOSES TO HELP ACHIEVE THEIR AIMS. THIS MIGHT INCLUDE (BUT IS NOT LIMITED TO), THE RIGHT TO USE THEM IN THEIR PRINTED AND ONLINE PUBLICITY, SOCIAL MEDIA, PRESS RELEASES AND FUNDING APPLICATIONS.
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

IF YOU HAVE ANY OF THESE CONDITIONS, WE RECOMMEND YOU CHECK WITH YOUR DR. TO RECEIVE WHOLE BODY CRYOTHERAPY:

HIGH BLOOD PRESSURE
KIDNEY OR URINARY TRACT DISEASE
JOINT DISEASES
ANY HEART DISORDERS
STROKE
MIGRAINES
HEART ATTACK IN PREVIOUS 6 MONTHS
AREAS OF NUMBNESS
RESPIRATORY DISEASES
DIABETES
PARALYSIS

MEDICAL INFORMATION (LIST MEDICATIONS TAKING AND DOSES)
WHAT ARE YOU HOPING TO ACHIEVE? *
IMPROVE ATHLETIC PERFORMANCE
RECOVERY FROM INJURY, ILLNESS OR SURGERY
BEAUTY & WELLNESS
HOW DID YOU HEAR ABOUT US?*

If Other, please specify:
I GRANT ALAMO CITYCRYOTHERAPY, LLC FULL RIGHTS TO USE THE IMAGES RESULTING FROM THE PHOTOGRAPHY/VIDEO FILMING, AND ANY REPRODUCTIONS OR ADAPTATIONS OF THE IMAGES FOR FUNDRAISING, PUBLICITY OR OTHER PURPOSES TO HELP ACHIEVE THEIR AIMS. THIS MIGHT INCLUDE (BUT IS NOT LIMITED TO), THE RIGHT TO USE THEM IN THEIR PRINTED AND ONLINE PUBLICITY, SOCIAL MEDIA, PRESS RELEASES AND FUNDING APPLICATIONS.
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

IF YOU HAVE ANY OF THESE CONDITIONS, WE RECOMMEND YOU CHECK WITH YOUR DR. TO RECEIVE WHOLE BODY CRYOTHERAPY:

HIGH BLOOD PRESSURE
KIDNEY OR URINARY TRACT DISEASE
JOINT DISEASES
ANY HEART DISORDERS
STROKE
MIGRAINES
HEART ATTACK IN PREVIOUS 6 MONTHS
AREAS OF NUMBNESS
RESPIRATORY DISEASES
DIABETES
PARALYSIS

MEDICAL INFORMATION (LIST MEDICATIONS TAKING AND DOSES)
WHAT ARE YOU HOPING TO ACHIEVE? *
IMPROVE ATHLETIC PERFORMANCE
RECOVERY FROM INJURY, ILLNESS OR SURGERY
BEAUTY & WELLNESS
HOW DID YOU HEAR ABOUT US?*

If Other, please specify:
I GRANT ALAMO CITYCRYOTHERAPY, LLC FULL RIGHTS TO USE THE IMAGES RESULTING FROM THE PHOTOGRAPHY/VIDEO FILMING, AND ANY REPRODUCTIONS OR ADAPTATIONS OF THE IMAGES FOR FUNDRAISING, PUBLICITY OR OTHER PURPOSES TO HELP ACHIEVE THEIR AIMS. THIS MIGHT INCLUDE (BUT IS NOT LIMITED TO), THE RIGHT TO USE THEM IN THEIR PRINTED AND ONLINE PUBLICITY, SOCIAL MEDIA, PRESS RELEASES AND FUNDING APPLICATIONS.
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

IF YOU HAVE ANY OF THESE CONDITIONS, WE RECOMMEND YOU CHECK WITH YOUR DR. TO RECEIVE WHOLE BODY CRYOTHERAPY:

HIGH BLOOD PRESSURE
KIDNEY OR URINARY TRACT DISEASE
JOINT DISEASES
ANY HEART DISORDERS
STROKE
MIGRAINES
HEART ATTACK IN PREVIOUS 6 MONTHS
AREAS OF NUMBNESS
RESPIRATORY DISEASES
DIABETES
PARALYSIS

MEDICAL INFORMATION (LIST MEDICATIONS TAKING AND DOSES)
WHAT ARE YOU HOPING TO ACHIEVE? *
IMPROVE ATHLETIC PERFORMANCE
RECOVERY FROM INJURY, ILLNESS OR SURGERY
BEAUTY & WELLNESS
HOW DID YOU HEAR ABOUT US?*

If Other, please specify:
I GRANT ALAMO CITYCRYOTHERAPY, LLC FULL RIGHTS TO USE THE IMAGES RESULTING FROM THE PHOTOGRAPHY/VIDEO FILMING, AND ANY REPRODUCTIONS OR ADAPTATIONS OF THE IMAGES FOR FUNDRAISING, PUBLICITY OR OTHER PURPOSES TO HELP ACHIEVE THEIR AIMS. THIS MIGHT INCLUDE (BUT IS NOT LIMITED TO), THE RIGHT TO USE THEM IN THEIR PRINTED AND ONLINE PUBLICITY, SOCIAL MEDIA, PRESS RELEASES AND FUNDING APPLICATIONS.
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

IF YOU HAVE ANY OF THESE CONDITIONS, WE RECOMMEND YOU CHECK WITH YOUR DR. TO RECEIVE WHOLE BODY CRYOTHERAPY:

HIGH BLOOD PRESSURE
KIDNEY OR URINARY TRACT DISEASE
JOINT DISEASES
ANY HEART DISORDERS
STROKE
MIGRAINES
HEART ATTACK IN PREVIOUS 6 MONTHS
AREAS OF NUMBNESS
RESPIRATORY DISEASES
DIABETES
PARALYSIS

MEDICAL INFORMATION (LIST MEDICATIONS TAKING AND DOSES)
WHAT ARE YOU HOPING TO ACHIEVE? *
IMPROVE ATHLETIC PERFORMANCE
RECOVERY FROM INJURY, ILLNESS OR SURGERY
BEAUTY & WELLNESS
HOW DID YOU HEAR ABOUT US?*

If Other, please specify:
I GRANT ALAMO CITYCRYOTHERAPY, LLC FULL RIGHTS TO USE THE IMAGES RESULTING FROM THE PHOTOGRAPHY/VIDEO FILMING, AND ANY REPRODUCTIONS OR ADAPTATIONS OF THE IMAGES FOR FUNDRAISING, PUBLICITY OR OTHER PURPOSES TO HELP ACHIEVE THEIR AIMS. THIS MIGHT INCLUDE (BUT IS NOT LIMITED TO), THE RIGHT TO USE THEM IN THEIR PRINTED AND ONLINE PUBLICITY, SOCIAL MEDIA, PRESS RELEASES AND FUNDING APPLICATIONS.
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

IF YOU HAVE ANY OF THESE CONDITIONS, WE RECOMMEND YOU CHECK WITH YOUR DR. TO RECEIVE WHOLE BODY CRYOTHERAPY:

HIGH BLOOD PRESSURE
KIDNEY OR URINARY TRACT DISEASE
JOINT DISEASES
ANY HEART DISORDERS
STROKE
MIGRAINES
HEART ATTACK IN PREVIOUS 6 MONTHS
AREAS OF NUMBNESS
RESPIRATORY DISEASES
DIABETES
PARALYSIS

MEDICAL INFORMATION (LIST MEDICATIONS TAKING AND DOSES)
WHAT ARE YOU HOPING TO ACHIEVE? *
IMPROVE ATHLETIC PERFORMANCE
RECOVERY FROM INJURY, ILLNESS OR SURGERY
BEAUTY & WELLNESS
HOW DID YOU HEAR ABOUT US?*

If Other, please specify:
I GRANT ALAMO CITYCRYOTHERAPY, LLC FULL RIGHTS TO USE THE IMAGES RESULTING FROM THE PHOTOGRAPHY/VIDEO FILMING, AND ANY REPRODUCTIONS OR ADAPTATIONS OF THE IMAGES FOR FUNDRAISING, PUBLICITY OR OTHER PURPOSES TO HELP ACHIEVE THEIR AIMS. THIS MIGHT INCLUDE (BUT IS NOT LIMITED TO), THE RIGHT TO USE THEM IN THEIR PRINTED AND ONLINE PUBLICITY, SOCIAL MEDIA, PRESS RELEASES AND FUNDING APPLICATIONS.
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

IF YOU HAVE ANY OF THESE CONDITIONS, WE RECOMMEND YOU CHECK WITH YOUR DR. TO RECEIVE WHOLE BODY CRYOTHERAPY:

HIGH BLOOD PRESSURE
KIDNEY OR URINARY TRACT DISEASE
JOINT DISEASES
ANY HEART DISORDERS
STROKE
MIGRAINES
HEART ATTACK IN PREVIOUS 6 MONTHS
AREAS OF NUMBNESS
RESPIRATORY DISEASES
DIABETES
PARALYSIS

MEDICAL INFORMATION (LIST MEDICATIONS TAKING AND DOSES)
WHAT ARE YOU HOPING TO ACHIEVE? *
IMPROVE ATHLETIC PERFORMANCE
RECOVERY FROM INJURY, ILLNESS OR SURGERY
BEAUTY & WELLNESS
HOW DID YOU HEAR ABOUT US?*

If Other, please specify:
I GRANT ALAMO CITYCRYOTHERAPY, LLC FULL RIGHTS TO USE THE IMAGES RESULTING FROM THE PHOTOGRAPHY/VIDEO FILMING, AND ANY REPRODUCTIONS OR ADAPTATIONS OF THE IMAGES FOR FUNDRAISING, PUBLICITY OR OTHER PURPOSES TO HELP ACHIEVE THEIR AIMS. THIS MIGHT INCLUDE (BUT IS NOT LIMITED TO), THE RIGHT TO USE THEM IN THEIR PRINTED AND ONLINE PUBLICITY, SOCIAL MEDIA, PRESS RELEASES AND FUNDING APPLICATIONS.
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

IF YOU HAVE ANY OF THESE CONDITIONS, WE RECOMMEND YOU CHECK WITH YOUR DR. TO RECEIVE WHOLE BODY CRYOTHERAPY:

HIGH BLOOD PRESSURE
KIDNEY OR URINARY TRACT DISEASE
JOINT DISEASES
ANY HEART DISORDERS
STROKE
MIGRAINES
HEART ATTACK IN PREVIOUS 6 MONTHS
AREAS OF NUMBNESS
RESPIRATORY DISEASES
DIABETES
PARALYSIS

MEDICAL INFORMATION (LIST MEDICATIONS TAKING AND DOSES)
WHAT ARE YOU HOPING TO ACHIEVE? *
IMPROVE ATHLETIC PERFORMANCE
RECOVERY FROM INJURY, ILLNESS OR SURGERY
BEAUTY & WELLNESS
HOW DID YOU HEAR ABOUT US?*

If Other, please specify:
I GRANT ALAMO CITYCRYOTHERAPY, LLC FULL RIGHTS TO USE THE IMAGES RESULTING FROM THE PHOTOGRAPHY/VIDEO FILMING, AND ANY REPRODUCTIONS OR ADAPTATIONS OF THE IMAGES FOR FUNDRAISING, PUBLICITY OR OTHER PURPOSES TO HELP ACHIEVE THEIR AIMS. THIS MIGHT INCLUDE (BUT IS NOT LIMITED TO), THE RIGHT TO USE THEM IN THEIR PRINTED AND ONLINE PUBLICITY, SOCIAL MEDIA, PRESS RELEASES AND FUNDING APPLICATIONS.
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

IF YOU HAVE ANY OF THESE CONDITIONS, WE RECOMMEND YOU CHECK WITH YOUR DR. TO RECEIVE WHOLE BODY CRYOTHERAPY:

HIGH BLOOD PRESSURE
KIDNEY OR URINARY TRACT DISEASE
JOINT DISEASES
ANY HEART DISORDERS
STROKE
MIGRAINES
HEART ATTACK IN PREVIOUS 6 MONTHS
AREAS OF NUMBNESS
RESPIRATORY DISEASES
DIABETES
PARALYSIS

MEDICAL INFORMATION (LIST MEDICATIONS TAKING AND DOSES)
WHAT ARE YOU HOPING TO ACHIEVE? *
IMPROVE ATHLETIC PERFORMANCE
RECOVERY FROM INJURY, ILLNESS OR SURGERY
BEAUTY & WELLNESS
HOW DID YOU HEAR ABOUT US?*

If Other, please specify:
I GRANT ALAMO CITYCRYOTHERAPY, LLC FULL RIGHTS TO USE THE IMAGES RESULTING FROM THE PHOTOGRAPHY/VIDEO FILMING, AND ANY REPRODUCTIONS OR ADAPTATIONS OF THE IMAGES FOR FUNDRAISING, PUBLICITY OR OTHER PURPOSES TO HELP ACHIEVE THEIR AIMS. THIS MIGHT INCLUDE (BUT IS NOT LIMITED TO), THE RIGHT TO USE THEM IN THEIR PRINTED AND ONLINE PUBLICITY, SOCIAL MEDIA, PRESS RELEASES AND FUNDING APPLICATIONS.
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

IF YOU HAVE ANY OF THESE CONDITIONS, WE RECOMMEND YOU CHECK WITH YOUR DR. TO RECEIVE WHOLE BODY CRYOTHERAPY:

HIGH BLOOD PRESSURE
KIDNEY OR URINARY TRACT DISEASE
JOINT DISEASES
ANY HEART DISORDERS
STROKE
MIGRAINES
HEART ATTACK IN PREVIOUS 6 MONTHS
AREAS OF NUMBNESS
RESPIRATORY DISEASES
DIABETES
PARALYSIS

MEDICAL INFORMATION (LIST MEDICATIONS TAKING AND DOSES)
WHAT ARE YOU HOPING TO ACHIEVE? *
IMPROVE ATHLETIC PERFORMANCE
RECOVERY FROM INJURY, ILLNESS OR SURGERY
BEAUTY & WELLNESS
HOW DID YOU HEAR ABOUT US?*

If Other, please specify:
I GRANT ALAMO CITYCRYOTHERAPY, LLC FULL RIGHTS TO USE THE IMAGES RESULTING FROM THE PHOTOGRAPHY/VIDEO FILMING, AND ANY REPRODUCTIONS OR ADAPTATIONS OF THE IMAGES FOR FUNDRAISING, PUBLICITY OR OTHER PURPOSES TO HELP ACHIEVE THEIR AIMS. THIS MIGHT INCLUDE (BUT IS NOT LIMITED TO), THE RIGHT TO USE THEM IN THEIR PRINTED AND ONLINE PUBLICITY, SOCIAL MEDIA, PRESS RELEASES AND FUNDING APPLICATIONS.
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

IF YOU HAVE ANY OF THESE CONDITIONS, WE RECOMMEND YOU CHECK WITH YOUR DR. TO RECEIVE WHOLE BODY CRYOTHERAPY:

HIGH BLOOD PRESSURE
KIDNEY OR URINARY TRACT DISEASE
JOINT DISEASES
ANY HEART DISORDERS
STROKE
MIGRAINES
HEART ATTACK IN PREVIOUS 6 MONTHS
AREAS OF NUMBNESS
RESPIRATORY DISEASES
DIABETES
PARALYSIS

MEDICAL INFORMATION (LIST MEDICATIONS TAKING AND DOSES)
WHAT ARE YOU HOPING TO ACHIEVE? *
IMPROVE ATHLETIC PERFORMANCE
RECOVERY FROM INJURY, ILLNESS OR SURGERY
BEAUTY & WELLNESS
HOW DID YOU HEAR ABOUT US?*

If Other, please specify:
I GRANT ALAMO CITYCRYOTHERAPY, LLC FULL RIGHTS TO USE THE IMAGES RESULTING FROM THE PHOTOGRAPHY/VIDEO FILMING, AND ANY REPRODUCTIONS OR ADAPTATIONS OF THE IMAGES FOR FUNDRAISING, PUBLICITY OR OTHER PURPOSES TO HELP ACHIEVE THEIR AIMS. THIS MIGHT INCLUDE (BUT IS NOT LIMITED TO), THE RIGHT TO USE THEM IN THEIR PRINTED AND ONLINE PUBLICITY, SOCIAL MEDIA, PRESS RELEASES AND FUNDING APPLICATIONS.
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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