***A scanned/image of Insurance Card must be attached to this form***
Signature of Individual (if 18 or older) ______________________________________
Signature of Parent/Guardian (if younger than 18) _______________________________
The following should be completed by the notary witnessing parent/guardian s signature.
The State of South Carolina the County of Spartanburg Before me, a Notary Public, on this day personally appeared ____________________ known to me (or proved to me on the oath of ______________________ to be the person whose name is subscribed to the foregoing instrnment and acknowledged to me that he executed the same for the purpose and consideration therein expressed. Given under my hand and the seal of the office this _______ day of _________ , A.D. __________.
Notary Public, Signature __________________________________________________
My commission expires the _________ day of ___________, A.D. _________________