Parent/Legal Guardian Consent to the Application of a Piercing
(Release and waiver of all claims for myself, minor and family.)

I, (parent/legal guardian name):________________________________________
am the parent/legal guardian of (minor’s name):___________________________
Address:___________________________________________________________
City:_________________________ State:______________ Zip:______________
Phone:_____________________________________________________________

I acknowledge that by signing this document I have been advised by the facts and matters set forth below and agree as follows:

1) I am consenting to my son/daughter or minor for whom I am legal guardian to have a piercing of (description of piercing):______________________________

2) I believe that my son/daughter or minor for whom I am legal guardian of is making an informed and conscious decision to have a piercing applied to (body part):___________________________________________________________

3) I have also read, signed and agreed to the Consent to the Application of a Piercing Release and Waiver of all Claims form, on the behalf of my son/daughter or minor for whom I am legal guardian.

4) I am accepting all legal and moral responsibility on behalf of my son/daughter or minor for whom I am legal guardian for their choice to be pierced.

Today’s Date: _____________________________________________________
(printed name of piercer): ___________________________________________
(signature of piercer): ______________________________________________
Parent/Legal Guardian Signature: _____________________________________
Minor’s Signature: _________________________________________________
State/Commonwealth of: ___________________________________________
County/City of: ___________________________________________________

This instrument was acknowledged before me on this ________ day of ________
By ________________________________________________________________
Notary Public: ______________________________________________________
Notary Public Stamp: ________________________________________________

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