Minor Consent Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Guardian/Parent Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Other Emergency Contact
First Name
Last Name
Phone Number
Please enter a valid phone number.
Any important medical information, such as allergies:
The undersigned does hereby authorize Custom Fitness, LLC and Ryan Claros, PT and/or Tasi Ada, PT consent to examine and treat the above mentioned minor by the Custom Fitness Team without a Parent or Guardian present.
Submit
Should be Empty: