Health Restored General Minor Disclaimer Disclaimer for Minors General Disclaimer for Minors Please fill in the information below as it correlates to the Minor Disclaimer document above. By filling out and signing this document, you are authorizing that you understand this document and everything you are submitting is true and accurate to the best of your knowledge, and in doing so will legally bind yourself to this document. A physical version of this disclaimer to be used instead of the digital one, as well as a copy of this signed document can be made available upon request. Initials of Legal Guardian (example: AH) * Name of Minor (First Middle Last): * Name of Legal Guardian (First Middle Last): * Signature of Legal Guardian * Clear Date * Address * Address Street Street Street 2 (apt, unit, PO box, etc.) Street 2 (apt, unit, PO box, etc.) City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Phone Number * E-Mail Address * Witnessed by (if applicable) Submit
