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APPOINTMENT DATE: APPOINTMENT TIME 1-EJ) ---,UE1' M"0N 2306 East St Tracy, Ca 95376 7 2o9-835-8413 TATTOO PIERC ra RELEASE FORM 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 Tattoo, Permanent Cosmetic Make-Up or Body Piercing by virtue of sections 1542 of the California Civil Code. This rule applies to the following persons and entities those that may work as an Agent, Employee or Unpaid volunteer, of Blue Moon, this release applies to the following Contractor, Director, Representative. person and entities those that may work written and or printed media advertisements. In addition to this release..) agree not to hold the persons and entities mentioned above responsible for any and all liabilities or claims made by other individual's as a result of my actions during, and after any Tattoo or Body Piercing procedure or Service. I have read this release form and fully understand the content of this four ----J\ I hereby certify with my initials that I m physically fit and that I fell sufficient to have this Tattoo or Body ---�/ Piercing service performed. I do not have any communicabledioseases such as AIDS/HIV, Hepatitis C, Hepatitis B, or Tuberculosis In this release. I m certifying that I m not pregnant, or under the influence if any substance including alcohol. I am not a diabetic or if I m I have informed the Taboo Artist or Body Modifier of this fact. I.acknowledge that there is a non-refundable (Permanent Make-up. piercing or taboo). non-transferable minimum deposit of$50 required for all Service Appointments. I have read and understand this release without a question and 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 sign the Guardian Section of the release form, I declare under penalty of penury that I am the true guardian of the mino and will not hold Blue moon accountable in ANY shape or fore,. Date Artist - ID CHECKED Please have ID Present Name IC State PIERCING Service $ Age DOB i__Phone Je-, elnCost $ City State Zip Code Email ( optional ) TATTOO COST_ $ TATTOO DEPOSITE_$ Signature Guardian Signature BALANCE DUE _ $ I Testify That I am The Legal Guardian of the person get`:ino the service. COMMENTS Thank You !!\