Date of Appointment *

Submission date of this waiver has to reflect same day as appointment.

MM

DD

YYYY

Parent/Legal Guardian's Name *

First Name

Last Name

Minor's Name *

First Name

Last Name

I am leaving my child without a legal guardian at The Colour Bar a Cynthia Diersen Salon LLC during their hair appointment. I understand that The Colour Bar a Cynthia Diersen Salon LLC is not a licensed childcare service and is not responsible for my child. I take full responsibility should an emergency arise. The Colour Bar a Cynthia Diersen Salon will not allow the child to make any decisions to their hair care without my (the parent/legal guardian) consent. *

I Agree

Electronic Form Signature *

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

Click to Sign Electronically