PARENTAL/GUARDIAN CONSENT FORM

I/We, parents or guardian(s) of (Print Name)_____________________

do hereby give permission for the above named minor to participate in a hypnotic session.

 We absolve all parties concerned with this session from any and all claims.

(PLEASE PRINT)

Name______________________________________ 

Street Address________________________________

City_____________________________ State_________ ZIP_________

Telephone #________________________

Signature__________________________  Date____________

Signature__________________________  Date____________

15 North Main Street    Bellingham, MA 02019

(508) 478-8500    FAX (508) 478-8600

joe@packard.name 

Dynamic Mind Institute