Minor Massage Liability Waiver & Parental Consent
Provide the minor’s details and your consent to authorize massage/bodywork, acknowledge risks, and sign the release on the minor’s behalf.
Minor's Full Name
*
First Name
Last Name
Minor's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Legal Guardian Full Name
*
First Name
Last Name
Relationship to Minor
*
Parent/Legal Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Legal Guardian Email Address
*
example@example.com
Parental/Legal Guardian Consent
*
Acknowledgments & Waiver
I understand that massage/bodywork is not a substitute for medical diagnosis or treatment and that it is recommended I consult a physician for any physical ailment.
I acknowledge that potential risks of massage/bodywork include, but are not limited to: soreness, bruising, discomfort, aggravation of an existing condition, allergic or skin reactions, or other injury.
I confirm that I have disclosed all relevant health information regarding the minor and agree to notify the massage therapist of any changes in the minor's health status.
I voluntarily assume all risks associated with massage/bodywork for the minor.
I release and hold harmless Sari Serenity, its owners, employees, contractors, therapists, and agents to the fullest extent permitted by law, without waiving rights that cannot legally be waived.
I acknowledge that I am signing on behalf of the minor and agree to the terms of this waiver and consent.
Parent/Legal Guardian Electronic Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
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