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Consent For Collection of Child's Information From Parent |
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| For Collection of Child's Information and for Child's Participation in Interactive Activities in which the Child May Disclose Information. |
If you agree to provide consent for the
limited collection of information about your child as provided for above,
and for your child's participation in the interactive activities corresponding
to the boxes you check below, please sign below and send this form to
us via mail to: Cancer Birthday Headquarters,  to verify your consent. Please check the appropriate box (es) below to indicate which activities on the website your child may participate in: [ _ ] Story Submissions: By checking on this box, you consent to your child's participation in the Capricorn Birthday story submission activity, in which your child may submit a story to Cancer Birthday for posting on the website for others to read. Your child's story will be accompanied by your child's first name and state of residence. [ _ ] Contests/Games & Drawings: By checking on this box, you consent to your child's participation in online contests and games that require personally identifiable information to play. Some contests may include prizes in which winning contestants' names are entered into a random-selection drawing for free prizes. Winner's first name and state of residence will be displayed online. [ _ ] Chat Room: By checking this box, you consent to your child's participation in the Cancer Birthday chat room, in which your child may post information for others to read and respond to. We encourage your child to use an alias when using the chat room, but cannot control what information your child decides to provide in the chat room. [ _ ] Gift Registry: By checking this box, you consent to your child’s participation in the Cancer Birthday Gift Registry in which your child may list her favorite Cancer Birthday products. Only individuals who are provided with an access code by you or your child will have access to the gift list. I, __________________, the parent or legal guardian of __________________ give permission for Cancer Birthday to collect and use information about my child as provided for above, and for my child to participate in any of the following activities for which I have checked the corresponding box above. I also understand that Cancer Birthday has no control over the content of submission made pursuant to your child’s participation in the Chat rooms or story/games/contest/drawing submissions. If my child uses the Chat Room or submits stories, drawings or contest submissions to Cancer Birthday, my child may post his/her e-mail address or other personally identifiable information, within the body of the submission, that other website visitors may be able to view. I understand that my child may lose access to the Cancer Birthday Chat Room, or any other online activities, if he/she violates the rules or behaves inappropriately. Cancer Birthday also reserves the right to disallow access to the site, in its sole discretion, for any reason that it deems appropriate. [ _ ] By checking this box I confirm I have read page all policies, privacy policy, under age 13 privacy policy, website useage agreement and agree to the terms of service on this date and usage agreements for my child under age 13. Parent's signature:_____________________________ Date Signed:________________________ Note: The staff at Cancer Birthday, Inc. works hard to ensure that this site is safe. If you have any questions about our registration procedure, monitoring policies or to suggest improvements, feel free to write us. This policy was last updated on 03/19/2005. Page 2 of 2. Page [1] |
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NOTICE: Visit www.ftc.gov/kidzprivacy for Information from the Federal Trade Commission about protecting children's privacy online. |
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Please review our Privacy Statement/Children's Statement, which
provides additional information regarding Cancer Birthday's privacy policies.
[1] Parent or Guardian: In order to provide your consent, please print out this form, fill it out, and mail it to:  Unfortunately, no submissions can be accepted by e-mail! If you are having trouble printing out this form please email or write us and we will send you a printed form or a Acrobat .pdf file to print. You may also contact us, at the fax number or address provided above, to review your child's personal information at any time, or to request to have any personal information about your child deleted. You may also contact us in this manner at any time to withdraw your consent, or to refuse to allow any further participation by your child in any of the website activities. We will need you to provide us with your password to access your child's information. Please register by providing the information below: Cancer Birthday User Information: Parent's e-mail address:_________________________ Child's e-mail address:__________________________ Parent’s Address: _____________________________ __________________________________________ Child's name:________________________________ Gender: ____________________________________ Parent's name: _______________________________ Parent's Phone Number: ________________________ (Note: Will be used only if there is a problem with the registration.) Cancer Birthday User Names Please provide your choices of a user name and password for your child. Please be sure to use a made-up user name. This helps to protect your child's identity. Please give us three different choices, in case someone has already picked one of your names. This is very important since we will be creating the user names for you. All user names must be at least three characters long and contain no spaces or symbols. If all of the names you have chosen are taken we will create a variation of the first choice. Username choice 1:_____________________________ Username choice 2:_____________________________ Username choice 3:_____________________________ Password:____________________________________ Note: your password can not contain spaces or symbols, i.e., !@#%^&*() ' "? / < >..etc. It needs to be between 8 and 15 characters in length and is "case sensitive" and only uses alphanumeric characters from a-z, 0-9. *image dimmed to prevent web robots from automatically harvesting information. |
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