Minor's Full Name:
Minor's Date of Birth:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
The undersigned do hereby authorize
Person that may bring your child to our office.
Parent or Guardian Signature:
Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent or Guardian Print Name:
Best Contact Number of Parent or Guardian:
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Submit
Should be Empty: