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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