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Model Waiver And Release -Form Fill

Section One
Q1

Name

First Name
Q2

Name

Last Name
Q3

Address

Street Address
Q4

Address

Street Address Line 2
Q5

Address

City
Q6

Address

State / Province
Q7

Address

Postal / Zip Code
Q8

Phone Number
Q9

Email
Q10

How did you hear about us?
Q11

Social Media Handle
Q12

I, the client herein signed, certify that I have read and had explained to me and fully understand the above Waiver and Release Form. I certify that I have consulted with the Permanent Makeup Artist and have read all applicable literature given to me. I accept the explanation of potential complications and risks described herein. I certify I am of sound mind, and I am fully capable of executing this waiver and release form for myself. I, the undersigned client, acknowledge and fully understand that there might be other unknown risks not reasonably foreseeable at this time. I, the client herein signed, for the purposes of documentation, hereby consent to “before and after” photographs.
Q13

I, the client herein signed, hereby give the absolute right and unrestricted permission to take, use, and display photographic images of me, through any form of media (print, electronic, broadcast, or otherwise) at any location for art, advertising, media release new articles, marketing, publicity, archival, or any other lawful purpose. I waive any right to royalties or other compensation arising from or related use of photographic images of me.
Q14

Signature
Q15

Date

Date