PARENTAL/GUARDIAN CONSENT FORM

I/We, parents or guardian(s) of (Print Name)_____________________

do hereby give permission for the above named minor to participate in a hypnotic session.

I/We absolve all parties concerned with this session from any and all claims.

(PLEASE PRINT)

Name______________________________________

Street Address________________________________

City_____________________________ State_________ ZIP_________

Telephone #________________________

Signature__________________________  Date____________

Signature__________________________  Date____________

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