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Member Waiver

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2026 DW Membership Waiver

Complete this form if:

  1. You are a member in need of a valid waiver on file.​

  2. You are a member who needs to update their information on file.

  3. You are a member and need to add minors to your membership. 

Destination Wellness

2026 MEMBERSHIP

INTAKE FORM & RELEASE OF LIABILITY

Personal Information

Birthday
Month
Day
Year
Multi-line address

Emergency Contact

Health Information

Current Health Status
Good
Fair
Poor
Medical History (Check any that apply and provide details if necessary):
Allergies (Include Medication Allergies)
No known allergies
Yes*

Sauna Use

Previous experience with infrared saunas:
None
Some
Frequent
Primary reason for using the infrared sauna:
Frequency of intended sauna use:
None
One-time
Weekly
Monthly

Red Light Therapy Use

Previous experience with red light therapy:
None
Some
Frequent
Frequency of intended red light therapy use:
None
One-time
Weekly
Monthly

MEMBERSHIP POLICY

CONSENT AND AGREEMENT

Acknowledgment of Risks and Waiver of Liability - DW

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Date and Time:
Month
Day
Year
Time
HoursMinutes

Acknowledgment Of Risks and Waiver of Liability Infrared Sauna & Red Light Therapy

Health problems that are contraindicated for Infrared Sauna Use:

  • Pregnancy

  • Cardiovascular Issues (Like Heart Failure, Hypertension)

  • Fever/Infection

  • Acute Joint Injuries

  • Bleeding Disorders

  • Impaired Sweating (MS, Diabetes With Neuropathy)

  • Being Under the Influence of Alcohol/Drugs

    **If you have any of the above health related problems, you are not a good candidate for infrared sauna use and will need to be cleared by a medical professional before being able to participate.

Health problems that are contraindicated for Red Light Therapy:

  • Malignant Cancers

  • Eye Diseases

  • Recent Burns

  • Light Sensitivity

  • Hyperthyroidism

  • Fever/Infection

  • Epilepsy

  • Systemic Lupus Erythematosus (SLE)

  • Pregnancy

  • Severe Blood Loss/Bleeding

  • Heart Disease or Pacemaker

  • Use of Photosensitizing Medications

    **If you have any of the above health related problems, you are not a good candidate for red light therapy and will need to be cleared by a medical professional before being able to participate.

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Date and Time:
Month
Day
Year
Time
HoursMinutes

Privacy Acknowledgement

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Date and Time:
Month
Day
Year
Time
HoursMinutes

PARENT OR GUARDIAN

ADDITIONAL AGREEMENT


(Must be completed for participants under the age of 18)

In consideration of minor being permitted to participate in this activity, I further agree to indemnify and hold harmless Releasees from any claims alleging negligence which are brought by or on behalf of minor or are in any way connected with such participation by minor.

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Date and Time:
Month
Day
Year
Time
HoursMinutes

Destination Wellness

31 W Church Street

Newark, OH 43055

(740) 280-2031

lcdestinationwellness@gmail.com

www.lcsdestinationwellness.com

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