We/I the undersigned _____________________________, _______________________________(please print) hereby release and hold harmless Birth Balance (BB) and / or any agent thereof, its members, employees and associates, as well as any tub manufacturer or distributor from any and all responsibility or liability for maternal complications, infant morbidity or mortality, or injury to any or all persons in connection with use of said water birth tub, that may occur before, during and after labor and birth. We/I take full responsibility for the manner and purpose for which we/I use the tub.
Rental Clause
We understand the total rental fee for the tub is $250, which includes the $120 nonrefundable deposit fee and the $130 pickup fee. We understand the rental period is for 30 days with a 7 day period to return the tub. The rental period begins on the day that the tub is shipped, or handed over in person. We agree to pay an additional tub rental fee of $25 per week, for each additional week that the tub is not returned to the BB office after the rental period. To insure the rental of the tub, we agree to pay a $120 non-refundable deposit. We understand that the return of the tub via shipping costs or dropping it off at the BB office are the responsibility of the renter. The remaining rental fee of $130 will be paid upon the pick up of the tub in person as we go over the protocol for set up and take down of the tub.All assesories and the tub are in working condition upon rental. We/I, the undersigned, _________________________, ___________________________, agree to pay for or to replace any damaged pool assesories or damaged tub after our/my rental.
We/I acknowledge that all births should be attended by experienced and knowledgeable birth practitioners.
Signatures:
___________________________, _______________________________
Date: ___________________ Phone#: ____________________________
Due Date: ____________________________________________________
Date of Tub Pickup:________________________ (After the check is received, you will be called to set up a pick up appointment that is three weeks prior to the due date.)
To assure you a tub rental, this signed and mailed agreement plus the check deposit is necessary before you pick up the tub.
PAYMENT: #1_______________________________ #2_______________________________
MAIL CHECK and SIGNED RELEASE TO THE FOLLOWING ADDRESS:
Judith Elaine Halek, Birth Balance
309 W. 109th St., Apt. 6D, NYC, NY 10025
212-222-4349 Work
212-222-4349 Fax (Must call in to arrange fax setup first)
646-391-8308 Cell
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