Minor Intake Form

Required Authorizations

For Minors: Legal Guardian or Power of Attorney

Legal Guardian Name(Required)
Minor Client Name(Required)
Address(Required)
Drop files here or
Max. file size: 2 MB, Max. files: 3.

    Media Release and Marketing Authorization

    Do you consent to the Media Release and Marketing Authorization?(Required)
    Your full name typed in this field will serve as your signature to everything you have indicated above.