Course Registration Form

Name (as on your ID):

First NameMiddle NameLast Name

Preferred Name:

If Applicable

Date

Birth Date

MonthDayYear

Sex (as on your ID)

Preferred Pronouns

Email

example@example.com

Phone Number

Format: (000) 000-0000.

I am above the age of 18

Are you under the influence of drugs or alcohol?

Pregnant or Nursing?

I understand that saying yes to any of the above questions makes me ineligible for a tattoo under New York City's tattoo guidelines

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

List any Skin conditions that could effect the tattoo process (e.g. Rashes, eczema, infection, psoriasis, etc.)

List any other Medical Conditions that may affect the tattoo process (e.g. Diabetes, Cardiovascular Disease, Epilepsy, Blood-related disease etc.)

I have been fully informed of the inherent risks associated with getting a Tattoo. I fully understand that these risks, known and unknown, can lead to injury, including but not limited to: infection, scarring, difficulties in detecting melanoma and allergic reactions to tattoo pigment, latex, or soap. Having been informed of the potential risks, I still wish to proceed with the Tattoo and I freely accept and expressly assume any and all risks that may arise from the Body Art procedure.

I agree that the Artist/Technician and Breathe Free Tattoo LLC have given me full opportunity to ask any and all questions regarding my Tattoo, and all of my questions have been answered to my satisfaction.

I waive and release to the fullest extent of the law all of the Artists/Technicians and Breathe Free Tattoo LLC. from all liability whatsoever, for any and all claims or causes of action that I, my estate, heirs, executors, or assigns may have for personal injury or otherwise, including any direct and/or consequential damages, which result or arise from the application of my Tattoo, whether caused by the negligence or fault of either the Artist/Technician or Breathe Free Tattoo LLC.

I understand that I need to take care of the tattoo by following the instructions given to me by the Artist/Technician. I acknowledge that it is possible the tattoo can get infected, particularly if I do not follow the aftercare instructions given. If any "Touch-up" work to the tattoo is needed, I agree that the work will be done at my own expense.

I release all rights to any photographs taken of me and the tattoo and give full consent in advance to their use in print or electronic form.

I acknowledge that neither the Artist/Technician or Breathe Free LLC is responsible for the meaning or spelling of the symbol or text I have chosen. Variations in color and design may exist between the art I have selected and the actual tattoo. I also understand that over time, the colors and clarity of my tattoo will fade over time.

I confirm that the information I provided in this document is accurate and true.

Artist Name

Appointment Time

Short Description of Tattoo

Upload a Picture of your Photo ID (Must include Photo, Name, Address, and Birthdate)

Signature

Tattoo Consent Form