11-23-2005 Council Agenda - Laserfiche WebLink

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CONSENT TO APPLICATION OF TATTOO AND RELEASE AND WAIVER OF ALL CLAIMS Do you have any allergies to the following? (Y= yes. N= no) Are you currently? Antibiotics Soaps _ Metals Taking any medication? _ Type? _ Cosmetics _ Latex _ Alcohol _ Other: Pregnant Have a heart condition? _ Skin condition Other Do you now or have you ever had any communicable disease or infection? Hepatitis _ Tuberculosis _ Gonorrhea Syphilis Herpes HIV Staph _ Other Fainting or dizziness High Blood Pressure Subject to rashes _ Sensitive skin IV Drug use Diabetic Epileptic I acknowledge by signing this writing that I have been given the full opportunity to ask any and all questions I might have about obtaining a tattoo from my artist; and that all my questions have been answered to my full and total satisfaction. I specifically acknowledge that I have been advised of the facts and matters set forth below, and by my initials I agree as follows: _I acknowledge that it is not reasonably possible for my artist to determine whether 1 might have an allergic reaction to the dyes, pigments or processes used in my tattoo, and I agree to accept the risk that such a reaction is possible. _I acknowledge that infection is always possible, particularly in the event that 1 do not take proper care of my tattoo. _I acknowledge receipt of written instructions advising me of the proper care of my tattoo and I recognize the absolute necessity for following those instructions. I realize that variations in color and design may exist between any tattoo represented on paper selected by me and as ultimately applied to my body. _I acknowledge that a tattoo is considered permanent; that it can only be removed by a surgical procedure; that any removal may leave permanent scarring and disfigurement. _I acknowledge that /have truthfully represented to my artist that I amnover the age of eighteen (18) years; or that my parent or legal guardian is signing below because I am a minor. _I acknowledge that the obtaining of my tattoo is by my choice alone and I consent to the application of the tattoo _I acknowledge that I am not under the influence of dings or alcohol or any intoxicating substance at the time the tattoo is administered. thereby give my artist permission to copyright and/or use and/or publish photographic portraits or pictures of me or in which I may be included in whole or in part or reproductions thereof made through any media for art, advertising, or any other lawful purpose whatsoever. I waive any right I may have to inspect and/or approve the finished product or the use to which it may be applied. _I agree to release and forever discharge and hold harmless my artist and the studio in which my tattoo is applied from any and all claims, damages or legal actions arising from or connected in any way with my tattoo or the procedure and conduct used to apply my tattoo or the processing or production of any said pictures. ARTIST NAME (PLEASE PRINT) STUDIO OR EVENT ADDRESS TATTOO AND LOCATION CITY, STATE, ZIP TODAY'S DATE SIGNATURE PARENT /GUARDIAN SIGNATURE DATE OF BIRTH RELATIONSHIP TO CLIENT I.D. AND NUMBER - 2 6 - 16