WARNING: INDIVIDUALS WITH PHOTOSENSITIVE EPILEPSY OR OTHER NERVE CONDITIONS SENSITIVE TO FLICKERING LIGHT SHOULD NOT USE THE SENSORIUM OR LSV 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, LSV AND/OR VIBRASOUND. 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, DO NOT USE IF YOU HAVE ANY IMPLANTED OR ATTACHED MEDICAL DEVICE WITHOUT THE APPROVAL OF A QUALIFIED MEDICAL PROFESSIONAL BEFORE USING THE VIBRASOUND OR SENSORIUM LSV II. IMMEDIATELY DISCONTINUE USE OF THE SENSORIUM, LSV AND/OR VIBRASOUND 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 our sensory technologies, the undersigned states the following:
1. I am 18 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 do not have any implanted electronic medical devices (Pacemaker, Defibrillator, Pump, Etc.)
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.
9. I have read and understand the warnings set forth above.
Further, I agree to release and hold harmless InnerSense Inc., FWDFuture LLC, Veteran Holistic Group LLC, Reality Mgmt Technologies, Inc. and their owners, agents, employees, investors 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, LSV or any of the other equipment at this 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.
