Parental Consent Form
PARENTAL CONSENT FORM
In order to verify your consent for the collection, use and disclosure of your child’s personal information, please follow these steps:
1. Complete all fields below and sign this Parental Consent Form.
2. Scan and email the completed and signed Parental Consent Form to us at firstname.lastname@example.org.
Account Information (for child)
Child’s Full Name: _______________________________________________________
Date of Birth: _______________________________________________________
Parent/Legal Guardian’s Information
Full Name: _______________________________________________________
Relationship to the Child: _______________________________________________________
Email Address: _______________________________________________________
By providing the information above and signing this request, I hereby provide my consent for:
(a) my child to fully participate in the services from time to time; and
I understand that I may, at any time by emailing email@example.com.
(i) request to review my child’s personal information,
(ii) request for my child’s personal information to be modified or deleted; and
(iii) request that you stop collecting or using my child’s personal information.
I understand that I may consent to the collection and use of my child’s personal information without consenting to the disclosure of that information to third parties except for those engaged by you to provide and manage the services.
Signature of Parent/Legal Guardian
Date Signed: __________________