minertown.com

Consent to Collect, Retain and Use Child's Personal Information

This form must be filled out by the parent or legal guardian of the child. It should then be mailed to minortown.com at:
minertown.com
RR 2 Box 1440
McAlisterville, PA 17049, USA

I, as the parent/legal guardian of the child(ren) listed below, grant permission for minertown.com to collect, retain, and use the child(ren)'s personal information as noted below. All information collected by minertown.com will be used for internal purposes only, for marketing products, informing of sales and other information, and sales of products.

Child(ren) __________________________________________________________

Information allowed to collect, retain and use:

Email address(es) listed: _______________________________________________________________

Name(s): ______ Address(es): ______ Telephone Number(s): ______

Other (specify): _______________________________________________________

Signed: _____________________________________________________________
            (signature of parent/legal guardian)

Date _____________

Address of parent/legal guardian __________________________________________

___________________________________________________________________

Email of parent/legal guardian _____________________________________________

Note: Address and email of parent/legal guardian is only used for record keeping purposes in case of a question regarding parental consent