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Nva kl1\ 1 4i9'. k1'T IF, 2366 East St TTraev, Ca 95376 209-335-8413 I hereby initial to waive & release Blue Moon, for all and any Liabilities and therefore agree not to Sue for all or ,_any Liabilities, including any personal injury, or claim of any kind which here after occur to me as result of participation in any Tzi,110 ., Permanent Cosmetic Make -Up or Body Piercing by virtue of sections 1542 of the California Civil Code. This rule applies to t' m following persons and entities those that may work as an Agent, Contractor, Director, Representative, Employee or Unpaid volunk-ler, of Blue Moon; this release applies to the following person and entities those that may work written and or printed media 'adw rtisenr:nt :. Ir addition to this release. I agree not to hold the persons and entities mentioned above responsible for any and all liabilities or claims rnade by other individuals as a result of my actions during, and after any Tattoo or Body Piercing procedure or Service. I have read this rcicase form and fully understand the content of this form. I _ _ hereby certify with my initials that I am physically fit and that I feel sufficient to have this Tattoo or Body Piercing service performed. I do not have any communicable diseases such as AIDS/HIV, Hepatitis C, Hepatitis B, or Tuberculosis. In this release, I am certifying that I am not pregnant, or under the influence if any substance including alcohol. I am not a diabetic or if I arn, I have: informed the; Tattoo Artist or Body Modifier of this fact. I acknowledge that there is a non-refundable (Permanent Make-up, piercing or tattoo), non transferable minimum deposit of $50 required for all Service Appointments. I have read and understand this release Without a question Mnd release Blue Moon of any/all reliabilities, I declare under penalty of perjury that the information I have provided is true and correct. Also when I sign the Guardian Section of the release form, I declare lander penalty of perjury that I am the true guardian of the minor and Voll not hold Blue moon accountable in ANY shape or form. Name x State Age—DOB—/—/—Phone City State Zip Code Email ( optional ) Signature Guardian Signature I Testifv That I am The Legal Guardian of the person getting the service. ISD CHECKE"', Please have ID Present PIERCING Service $ Jewelry Cost $ TATTOO COST _ $ TATTOO ! ► BALANCE DUE $ NOTICE: TATTOO INK.DYES AND PIGMENTS HAVE NOT BEEN APPROVED BY THE FEDERAL: FOOD AND DRU="; A TIT.TTTTTCTn A'T/ITT AXI TTAT —TTI- TTT` A T TTi