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Please sign and have this notarized.
I hereby certify that I possess the intellectual and emotional maturity required to consent to sex. I have not in any way been coerced into signing this form, and I have not received, and do not expect to receive, any payment or remuneration whatsoever for performing the specified sex acts. I am 18 years or older and am not intoxicated with alcohol or drugs.
Kissing
I consent to being kissed on the mouth. I consent to being kissed on the face and neck. I will hold the kisser harmless and blameless for any hickies sustained during the above-listed forms of kissing.
Touching
I consent to being touching in the following manner: on my breasts inside of my clothes, on my buttocks inside of my clothes, and on my vaginal area inside of my clothes.
Oral Sex
I hereby give consent to oral sex (cunnilingus) being performed on me. If I choose to perform fellatio, I agree to allow my partner to ejaculate in my mouth. I consent to having oral sex performed on my anus (analingus).
Genital-to-Genital Contact without Penetration (Outercourse)
I agree to genital-to-genital contact, not including penetration (outercourse).
Vaginal Penetration
I consent to being vaginally penetrated by a full fist. I consent to being vaginally penetetrated by sex toys. I consent to vaginal penetration by a dildo. I consent to vaginal penetration by a vibrator. I consent to being vaginally penetrated by a penis. During penetration by a penis I require the use of a condom.
Anal Penetration
I consent to anal penetration by 2 fingers. I consent to anal penetration by sex toys. I consent to anal penetration with a vibrator. I consent to anal penetration by a penis. I consent to ejaculation within the anus during anal penetration.
Sexually Transmitted Diseases
I have now, or have had in the past, the following STDs: herpes, syphilis, gonorrhea, warts, chlamydia, AIDS, and hepatitis. (please circle which ones you've had)
Birth Control
I agree to use the following forms of birth control: diaphragm, cervical cap, IUD, birth control pills.
Signed by: ____________________________________
Print name: ___________________________________
Date: 07/08/2009