COPPA Notification and Parental Consent Form
Dear Parent or Guardian:
We are providing you with this Parental Consent Form because of a request to create a member account on the FaithStreams Communities website www.communities.faithstreams.com for a child under the age of 13. In order to comply with the Children's Online Privacy Protection Act, we will not knowingly allow a child under 13 to have an account without parental consent.
Please read the following carefully and follow the instructions below.
1) In order for your child to become a member of the FaithStreams Communities community, it is necessary for us to collect and maintain certain personal information (e.g., name, city, state, email address) concerning your child.
2) We will use your child's information only as described in our Privacy Statement, which can be viewed at http://communities.faithstreams.com/PrivacyandUse/tabid/18146/Default.aspx Generally, if you consent, we will use your child's information in the same manner that we use all personally identifiable information. We do not disclose information to third parties for marketing purposes.
3) With your consent, we will create a member account for your child on the FaithStreams Communities site, and notify you when the account has been created at the e-mail address you provide on the form below.
4) You may provide parental consent by printing and completing the form below and returning it to Lightworks New Media by fax or mail. You must complete a separate form for each child under the age of 13 for whom you are granting permission.
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PARENTAL CONSENT FORM
By completing and submitting the following form, I consent to have an account created for my child, and give permission for that child to use the FaithStreams Network community system. I also consent to Lightworks New Media and Faith and Values Media’s use of my child's information in accordance to their Privacy Policy and Terms of Use. I certify that I am at least 18 years old and am the parent or legal guardian of the child who is subscribing to the service.
Please complete the following form and follow the return instructions below.
First and Last Name of child subscriber:
_________________________________
Birth date of child subscriber: (Month/Day/Year)
__________________________________
Preferred Username for the child’s account:
_________________________________
Email Address of Parent or Guardian:
__________________________________
Daytime phone number of Parent or Guardian:
__________________________________
Signature of Parent or Guardian:
_________________________________
Print Parent or Guardian’s Name:
_________________________________
Date:
_________________________________
RETURN INSTRUCTIONS VIA FAX or US MAIL:
1) Be sure you have read all of the information above.
2) Complete the blanks.
3) Sign the form and print your name.
4) Fax the form to FaithStreams Communities c/o Lightworks New Media at (859) 422-1167 or mail to:
Lightworks New Media, Inc.
ATTN: COPPA
240 Blazer Parkway, Suite 240
Lexington, KY 40509