{"id":4933,"date":"2015-07-22T15:16:45","date_gmt":"2015-07-22T13:16:45","guid":{"rendered":"http:\/\/www.dalpasso.it\/modulo-per-pazienti-minorenni-2\/"},"modified":"2015-11-13T11:13:49","modified_gmt":"2015-11-13T10:13:49","slug":"form-for-minors","status":"publish","type":"page","link":"https:\/\/www.dalpasso.it\/en\/contacts\/to-ask-for-your-images\/form-for-minors\/","title":{"rendered":"Form for minors"},"content":{"rendered":"
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    The undersigned *\n<\/p>\n

    <\/span>\n<\/p>\n

    DOB*\n<\/p>\n

    <\/span>\n<\/p>\n

    (dd\/mm\/yyyy) *\n<\/p>\n

    <\/span>\n<\/p>\n

    Resident in *\n<\/p>\n

    <\/span>\n<\/p>\n

    Address *\n<\/p>\n

    <\/span>\n<\/p>\n

    E-mail*\n<\/p>\n

    <\/span>\n<\/p>\n

    Claiming to be a parent or Legal guardian of the child (Name and Surname)*\n<\/p>\n

    <\/span>\n<\/p>\n

    \n

    DECLARES\n<\/h4>\n

    that they wear an ocular prosthesis applied by Dalpasso s.r.l. with registered office in Reggio Emilia, via Turri n. 10 *\n<\/p>\n

    that they are aware of the legal consequences of providing false data or information *\n<\/p>\n

    that they have been informed by Dalpasso s.r.l. regarding the standards that govern the processing of sensitive data pursuant to Legislative Decree 196\/2003 *\n<\/p>\n

    holding harmless Dalpasso s.r.l. from all responsibility in relation to this request *\n<\/p>\n

    \n

    REQUESTS\n<\/h4>\n

    a copy of the photographic digital images of the mentioned minor taken and stored in the magnetic archives of the company Dalpasso s.r.l. to be sent to them\n<\/p>\n

    date on which photographs were taken *\n<\/p>\n