EFTA00305053.pdf

MODEL RELEASE FORM In consideration of the haircolor and hair care services to be performed without cost to me by J.C.Penney Corporation, Inc., I do hereby release and forever discharge J.C. Penney Corporation, Inc., its parent companies, affiliates and subsidiaries and each of their respective agents, directors, officers, stockholders, employees, representatives and all persons acting on their behalf (hereinafter collectively referred to as "jcp"), from all claims, demands, causes of action or liability (hereinafter "Claims") that may arise from any and all injuries I may incur as a result of the services performed and/or material used in connection with the application of cosmetic products furnished to me or applied to my hair, skin, nails, or other portions of my body by jcp. I represent that I have no history or occurrences of adverse skin reaction whether relating to the use of cosmetic products or otherwise and I hereby assume all risks to personal injuries which I may sustain as the result of such application whether caused by the materials or products used or the manner of services rendered by jcp. I understand and acknowledge that certain cosmetic products contain reactive chemicals, may induce allergic reactions in some persons, or for other reasons may require skin testing prior to application or use. I hereby waive any skin test related to the use of cosmetic products by jcp. I further hereby release jcp form any and all claims that may arise from any injuries I may incur as a result of or relating to waiving such testing. I realize in executing this release that I am freeing and holding jcp harmless from any and all possible actual or claimed conduct, either by way of act or omission by jcp, or any of its agents or representative, whether in the formulation or manufacture or application of the products to be used. I hereby grant to jcp the unrestricted, unlimited right and permission to use and reproduce, copyright, publish and exhibit in any form, any manner and in any media whatsoever, whether now existing or hereafter developed (including without limitation advertising, collateral, promotional materials and the Internet), any and all photographs, videotapes, or other means of reproduction of my physical likeness taken on the date hereof, without restriction to the date of use. EFTA00305053 I hereby waive any and all rights I may have to inspect or approve any of the finished or unfinished photographs, videotapes or other means of reproduction, or to approve the use made of any of such photographs, videotapes, reproductions referred to herein, so long as the uses are for lawful purposes. I am eighteen years of age or older, and I have carefully read the above and thoroughly understand its terms and meaning and I know of no reason why I am not free and competent to grant this release. Date: Signature Phone: ( ) Address City State Zip Code e-Mail Address Agency Name (If applicable) THIS AGREEMENT MAY NOT BE CHANGED OR MODIFIED ORALLY AND THE COMPLETE AGREEMENT IS AS ABOVE STATED Date: Service Performed Signature of Person Performing Service EFTA00305054 jcp Informed Consent Form jcp salon Customer ID Ii Last Name: First Name Middle ji Johanna Thuringen have been advised by Michael Albor at the jcpenney Company, Inc. Salon located at JCP Headquarters and understand the following: ❑ Perm/Relaxer/CHI Transformation System/CHI Ultimate Blowout Authorization The chemical service I have requested involves the application of chemicals which may cause damage to my, hair. skin. scalp or other parts of my person Signature Date Color Authorization Since my hair has been previously colored with permanent hair color treatment. I wish to forego a patch test at this time and authorize jcpenney to color my hair. I further understand that the hair color treatment involves the application of other chemicals, which may cause damage to my hair, skin. scalp. or other parts of my person Signature Date Parent/Guardian Consent ereby give my permission as parent or guardian of , who is years of age and is my , to receive the above referenced services at this salon. I have read and understand this Informed Consent Form andagree to all of its provisions. Signature Date pi I. Hair Removal Authorization The hair removal service I have requested involves the application of chemicals which may cause damage to my hair, skin, scalp or other parts of my person. 2. jcpenney team members will not perform the hair removal service I have requested if I have used Accutane within the past 6 months; if I have had injections for wrinkles or acne within the past 6 months, or have had any laser and/or peeling of the area that I wish to be treated, or have used any products containing Retin-A. (Retinoic Acid) within the last 3 months. I agree to refrain from this service sought if I have used any product containing Salicylic Acid or Glycolic Acid within the past month, or Alpha Hydroxyl Acid/or Benzyl Peroxide within the past week. I fully understand that this service will not be performed if any lymph glands have been removed. 3. I may not sunbathe or expose the treated area to sunlight or use a tanning bed. sunlamp. or any related device for a minimum of 24 hours after I receive hair removal services. 4. I understand that failure to follow these instructions and/or an adverse reaction to the application of chemicals may result in injury or damage. EFTA00305055 Signature Date Caregiver Consent jcpenney is not my caregiver. If I require the services of a caregiver, I am responsible for having my own caregiver be with me at the Salon to help me with mobility, personal cam and other physical safety matters. I will have my caregiver assist me in these matters while lam at the Salon—before, during, and after I actually receive Salon services. Signature Date N JCP Salon and The Salon by InStyle - Agency Consent for Cut/Color/Style Johanna Thuringer , authorize JCP Salon and The Salon by InStyle to do the following to my hair as agreed upon previously: trim and freshen color Signature Date EFTA00305056