the weekend of October 8th 2011
 

WNY Gamers Club: COPPA Permission Form

Instructions for a parent or guardian:

Please print this form out, complete it and mail to the mailing address below. Please (click here) for an Adobe Acrobat version suitable for printing. Forms will also be available at the event, but a Parent / Legal Guardian must be present at the time of signing. Sample form and mailing address is below:

Mailing Address:
WNY Gamers Club
151 Ames Ave
Tonawanda NY 14150

Please sign the form below and send to us.

I understand that my son/daughter will be playing games at Lan Party Extravaganza with possible rating "M for Mature".

Name of Child

______________________________________________________________

Parent / Legal Guardian FULL name

______________________________________________________________

Relation to child

______________________________________________________________

Signature

______________________________________________________________

Email Address

______________________________________________________________

Phone Number

______________________________________________________________

Date

______________________________________________________________