Minor w/Adult Waiver | Mi Smash Therapy

Minor with adult Waiver

To be completed by parent/legal guardian for minors 12 -17 years old.

Minor's First Name

Minor's Last Name

Minor's Address

City

State

Zip

Minor’s Date of Birth

This Parental Consent Agreement ("Agreement”) shall be effective as of the date the Parent(s) sign below by and between Mi Smash Therapy LLC (“MiST”) and the individual(s) identified as the Parents/Guardian below (singularly and collectively, the “Parents”). Parents represent and warrant they are legally responsible for the care, legal custody, and control of the minor listed above at all times, and are able to bind the minor to the Release & Waiver of Liability Agreement provided with this Parental Consent Agreement, of which Parents have been provided and the terms of which are incorporated by reference heron, which Parents hereby acknowledge having received and understanding. Parents expressly consent to the minor participating in the activities on the premises of MiST, and represent and warrant all minors are at least 12 years of age or older.

I accept terms & conditions

Parent(s) First Name

Parent's Last Name

Address is same as Minor's.

Parent's Address

City

State

Zip

Parent/Guardian Email

Relationship to Minor

I certifiy that I am 18 years of age or older. I understand that I will need to present a valid ID when I check-in.

In the event of an emergency, please contact the following person(s)

Emergency Contact

Phone Number

Your Signature

Date of Reservation

Electronic Signature Consent*

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

By clicking 'I Agree' below, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.

Thanks for submitting!