Authorization of Signing Authority

Authorization of Signing Authority
Client *

First NameLast Name
Parent/Guardian if Minor*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
I Parent First Name* Last Name* , residing at Street Address* Address Line 2* City* State* Zipcode* hereby authorize First Name* Last Name* identified by ID Number Id number *, to sign documents on my behalf for therapies provided by therapists of Hialeah Academy of Music LLC for my child Child Name* Child Last Name* . This authorization is valid from Date* to Date*
Parent/Guardian if Minor*
Parent/Guardian if Minor Photo*
Should be Empty: