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Media 360 Parental Consent Form for Unattended
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I am the parent and/or legal guardian of ________________________________,
who is between 12 and 17 years of age. I am aware that the minor named above will be purchasing time at Media
360. I understand that Media 360
will not control the person above from entering and exiting the store during
open hours. The minor will be
allowed to leave Media 360 at any time, and in the case of a rule infraction
may be asked to leave.
By my signature, I grant my permission to allow the above named minor to stay
at Media 360 unattended. I
perpetually release Media 360, its employees, owner, and sponsors from any and
all liability that may arise from my decision to allow a minor to stay
Unattended.
Signature of Parent or Legal Guardian (required)
__________________________________________________
Print Name of
Parent or Legal Guardian (required)
__________________________________________________
Address of Parent or Legal Guardian (required)
__________________________________________________
__________________________________________________
Telephone Number of Parent or Legal Guardian (required)
_________________________________
Date
_________________________________
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