Written Notarized Consent For Body Piercing Of A Minor Form printable pdf download

Written Notarized Consent For Body Piercing Of A Minor Form

Written Notarized Consent for Body Piercing of a Minor

Use of this form is voluntary and not required by the Department of Health. The form is provided as a

service to assist salons in complying with the record-keeping requirements of

Chapter 64E-19, Florida Administrative Code.

State of Florida

County of __________________________

Before me this ____________ day of __________________________, 20______,

personally appeared__________________________________________,

(Name of Parent/Guardian)

who, under oath or affirmation, makes the following statements under penalties of perjury:

I am the parent/legal guardian of ___________________________________,

(Name of Minor)

a minor, whose date of birth is _______________________, _______, ______,

(Month)

(Day)

(Year)

and I consent to the body piercing of _____________________________’s

(Name of Minor)

________________________________________________________________.

[Location(s) of Piercing(s)]

I accept that I must be present at the piercing if my child is under 16 years of age.

_________________________________

(Signature of Parent/Legal Guardian)

Sworn to/affirmed and subscribed before me this _______ day of ________________, 20___,

by ___________________________, who is personally known to me or who presented

_______________________________________________ as satisfactory identification.

(Form of identification)

___________________________________

(Signature of Notary)

___________________________________

(Name of Notary typed, stamped or printed)

(Notary Seal)

For Office Use Only

_____________________________

(Printed Name of Licensed Salon)

_____________________________

(Signature of Piercer)

_____________________________

(Printed Name of Piercer)

Written Notarized Consent For Body Piercing Of A Minor Form