Parental Consent Form

This form must be printed out and faxed back to us at the number below. Law requires us to obtain "Verifiable Parental Consent" before any child under the age of 13 may provide any information, including email addresses to us. In accordance with our Privacy Statement - we do not make any information obtained from any party available to any other company, party, individual, corporation, firm or entity, with the exception that posters who abuse the discussion forums are subject to having their posting activity reported to their Internet Service Provider.

However, inasmuch as registration for the discussion forms requires your email address for purposes of mailing back a password, we are required to obtain this consent

Your Name (Parent):_________________________________    Your Child's Name: _________________________________
You must provide a completed form for each child under the age of 13 that may post to this forum.

Your Child's Age____________ Your Date of Birth:________________________

Your Internet Service Provider (such as AOL, Earthlink, etc.):___________________________________
Your email address:____________________________Your Child's Email address:_____________________________
If your child has more than one email address, you must provide all email addresses in the space below.

I ____________________________________ (name of parent) certify that I have read the provisions of COPPA - Click HERE to read and as such, I am aware of my rights in this regard. I certify that my child __________________________________ (name of child) may post questions or participate in discussions with others on this/these discussion forums contained within wildxangel.com. I understand that I have the right to view the posts that my child may make, and be provided with any additional information I may request about these posts so long as the information is available to the site owner.

I may revoke my consent for my child to post at any time but must do so via FAX.

Please send this form to us via email in .doc format.