R-Rated Motion Picture Permission Form

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R-Rated Motion Picture
Vernon Square Cinema
1230 North Main Street, Viroqua, WI 54665
Permission Form
(608) 637-8800
Children Under 17 Years Of Age Must Be Accompanied by a Parent or Guardian, unless the permission form below is
completed. An R-rated motion picture may include: adult themes & language, as well as violence, drug abuse and/or
sexual content.
I _____________________________ give my child(ren) permission to watch an R-Rated film without my presence. I
understand that if I sign for other children, I take full responsibility for any complications concerning possible disagreements with
their parents.
Walk In
 Phone
Has Permission To Watch ___________________
Please list below the name of each child that has your permission:
▪______________________________
▪______________________________
▪______________________________
▪______________________________
▪______________________________
▪______________________________
SIGNATURE: _______________________________________
DATE: ___________________
------------------------------------------------------------------------------------------------------------
R-Rated Motion Picture
Vernon Square Cinema
1230 North Main Street, Viroqua, WI 54665
Permission Form
(608) 637-8800
Children Under 17 Years Of Age Must Be Accompanied by a Parent or Guardian, unless the permission form below is
completed. An R-rated motion picture may include: adult themes & language, as well as violence, drug abuse and/or
sexual content.
I _____________________________ give my child(ren) permission to watch an R-Rated film without my presence. I
understand that if I sign for other children, I take full responsibility for any complications concerning possible disagreements with
their parents.
Walk In
 Phone
Has Permission To Watch ___________________
Please list below the name of each child that has your permission:
▪______________________________
▪______________________________
▪______________________________
▪______________________________
▪______________________________
▪______________________________
SIGNATURE: _______________________________________
DATE: ___________________

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