YOUTH PERMISSION FORM

Please print this form, complete it, have a parent or guardian sign it, and fax to: 919-266-1977 or mail to:

Semroc Astronautics Corporation

Customer Service Department

P.O. Box 1271

Knightdale, North Carolina 27545

You need to file a "Permission Form" only once. This "Permission Form" allows you to provide information to Semroc Astronautics Corporation, subscribe to the "Online Astronautic Modeler" and/or join the "Semroc® Space Society". Parents can revoke this consent at any time by faxing or mailing a letter to the same address.

Child's Name Child's Birth Date
Address City
State Zip    Phone
Child's E-mail
Date  
  Parent's/Guardian's Name
  Parent's/Guardian's Signature