HIPAA
Compliance
If this form is for a child under the age of 18, a guardian must complete this section,I, First Name Last Name attest that I am the parent/legal guardian of Child's First Name Child's Last Name . I agree to allow him/her to participate in the ELITE Ambassadors Council. Parent/legal guardian's contact information: Area Code Phone Number , Street Address Address Line 2 City State Zip Email , Signature I agree to the following statements listed below:
If you are an adult, over the age of 18, type your name here, I First Name Last Name agree to the following statements below:
PARENT/LEGAL GUARDIAN SIGNATURE Signature SIGNATURE OF ELITE PARTICIPANT UNDER THE AGE OF 18 Signature
SIGNATURE OF ELITE PARTICIPANT, AGE 18+ Signature