Piercing Release Form (Minor)

Piercing Release Form

Tattoo Republic LLC Minor Piercing Consent and Liability Release Form
Take a clear picture of the front of the Minor's ID*
Take a clear picture of the front of the Parent/Guardian's ID*
Minor's Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
Relation to Minor*
Mother/Father, Legal Guardian
Email*
example@example.com
Minor's Age*
Type of Piercing Requested*
Industrial, Nostril, Septum etc.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Minor ID Type*
Parent/Guardian Drivers License #*
Minor's Date Of Birth*

MonthDayYear
Date
Parent/Guardian Date of Birth*

MonthDayYear
Date

Covid-19 Health Screening Questionnaire*

I do not have symptoms of COVID-19 and accept to follow the rules of the shop during my appointment.I have not had contact with anyone who may have symptoms of COVID-19 or get infected by the virus within 14 days.

If any provision, section, subsection, clause or phrase of this release is found to be
unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

I hereby declare that I am of legal age and the minor's Parent or Legal Guardian (and have provided valid proof of identification) and am competent to sign this Agreement. I declare that I release Tattoo Republic LLC, its employees, agents, artists or any representatives from all liabilities or damages that may result in a minor being pierced.
Minor's Signature

Clear
Parent/Guardian Signature

Clear
Should be Empty: