We, 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 waterbirth tub, that may occur before, during and after labor and birth. We take full responsibility for the manner and purpose for which we use the tub.

Rental Clause

We understand the rental fee for the tub is $150. 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 $75 non-refundable deposit for the tub. 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.

All assesories and the tub are in working condition upon rental. We, the undersigned,
_________________________,___________________________, agree to pay for or replace any damaged pool assesories or damaged tub after our rental.

We acknowledge that all births should be attended by experienced and knowledgeable birth practitioners.

Signatures: _____________________, _______________________________
Date ___________________ Phone#: ____________________________
Due Date: ____________________________________________________
Please indicate date that you would like tub to arrive at home or you will
pick it up at BB office: _____________________

Please send the signed agreement and the $75 deposit (made out to: Judith Halek OR Birth Balance) check to the following address:

Judith Halek
Birth Balance
309 W. 109th St.
Apt. 6D
NYC, NY  10025

(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.)

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