Parental Consent Form
In compliance with the Children's On-Line Privacy Protection Act (COPPA). Parental consent is required before we can collect any information from a child under age 13. Please review our privacy policy here : Privacy Policy
Parental Approval Required.
Your parent or guardian must approve your registration. You will
not be able to post until this approval is received. To create your
account, please print out this page and follow the directions given below.
For more information, contact
| Login Name: Please give alternate names in case your preferred login name is taken. |
__________________________________ |
| Publicly
Displayed Name: The name that will be displayed on the board |
___________________________________ |
| Email Address: This must be a valid email address. Your password will be mailed to you at this address |
___________________________________ |
| State: | ___________________________________ |
| Birth Date: | ___________________________________ |
| COPPA
Instructions: Yes, I have reviewed the information my child has submitted, and I have read the Privacy Policy for the web site. I understand that the profile information may be changed using the Log in and password for this registration. I understand that I may ask for this registration profile to be removed entirely. |
|
| Parent/Guardian Full Name: | ___________________________________ |
| Signature: | ___________________________________ |
| Relation to Child: | ___________________________________ |
| Telephone Number, Address, (or other offline contact method.): | ___________________________________
___________________________________ |
| Parent/Guardian Email Address: | ___________________________________ |
| Date: | ___________________________________ |
| Please sign and date this form and mail it to: | Sullivans 429 Upper Twin Blue Creek, Ohio 45616 740.858.4416 |