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I______________________________ represent that I am the parent or guardian of
___________________________________________________________ (Minor).
And that 1 have every right to contract for the minor. I have read this authorization and release before I signed it and I fully understand its contents. I consent to this authorization and release on the minor’s behalf.
Date:_________________________________
By:__________________________________(Signature)
By:__________________________________ (Print Name)
ADDRESS/TELEPHONE & FACSIMILE:
Taxpayer ID(S.S.):_________________________________
Driver’s License No.:________________________________
N.B. This consent form must be signed in conjunction with a MODEL release form; this consent also confirms that I have been shown the Photographers. . . Peter Francis Kearns
NATIONAL IDENTIFICATION SERVICE AUTHENTIC DOCUMENT
REF: 2003/1161087B DATED: