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MAIL IN REGISTRATION FOR FACE PAINTING & BODY ART CONVENTION
“CREATIVE CHAOS” March 11 – MARCH 5, 2012 Flamingo Casino & Hotel
c/o Karen Owens , FPBA Convention, 1959 Homefield Estates Dr, O’Fallon, MO 63366
NAME: ______Judy Gillette-Pelkey__________________________________________________________________________________
ADDRESS: _________9 Bridgeport Dr___________________________________________________________________________
CITY STATE ZIP
_Eagle Point, OR 97524________________________________________________________________________________________________
PHONE: _________541-538-2181____________________________________________________________________________
E-­MAIL: _____________jpjazzyjem@gmail.com_________________________________________________________________________
What are your interests? (circle all that apply)
Face Painting

Body Painting Henna Glitter Tattoos Fantasy Make Up
Airbrush FX Balloon Sculpting Business Classes Networking
Do you have a favorite tip or trick that you use?
_________________________________________________________________________________________________
What is your shirt size? xx-­‐large

By completing this registration I understand that I have read, understand and agree
to the following: I hereby covenant and agree to indemnify, save and hold I
HEREBY RELEASE, discharge, and covenant not to sue Artful Blessing, LLC and /or
Harrah’s, Flamingo, their owners, directors, agents, officers, independent contractors,
volunteers and employees, any sponsors, advertisers, and if applicable, owners and
lessors of premises, on which the convention takes place, (each considered one of the
Releasees herein) from all liability, claims, demands, losses or damages on my account
caused or alleged to be caused in whole or in part by the negligence of the Releasees or
otherwise; and I further agree that if, despite this release and waiver of liability,
assumption of risk, and indemnity agreement, I, or anyone on my behalf, makes a claim
against any of the Releasees, I will indemnify, save and hold harmless each of the
Releasees, from any litigation’s expenses, attorney fees, loss, liability, damage, or cost
which may incur as a result of any such claim. I have read this agreement, fully
understand its terms, understand that I have given up substantial rights by signing it and
have signed it freely and without any inducement or assurance of any nature and intend it
be a complete and unconditional release of all liability to the greatest extent allowed by
law and agree that if any portion of this agreement is held to be invalid, the balance,
notwithstanding, shall continue in full force and effect.
Printed Name of Participant: _______Judy Gillette-Pelkey________________________________________
Date: _____2-21-12__________
Signature: _______________________JGP______________________________________