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 AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone Number * E-Mail Address * Witnessed by (if applicable) Submit
