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Parental Consent Form

Consent of Parent or Adult Legal Guardian to Children Accessing PAX Programs Incorporated Web Site

As is stated more fully in our Privacy Policy Statement, we are under a legal obligation to obtain your consent to your child accessing our site. The Children’s Online Privacy Protection Act (COPPA) was enacted to protect the health, safety, and privacy of children under the age of 13. In addition, PAX’s own policy guidelines require your consent for anyone under the age of 18 to participate in the activities of our site. In accordance with the provisions of that act and other legal regulations, therefore, we wish to advise you that if your child proceeds to participate in our site activities, he/she at some point will be likely to be participating in a variety of electronic online communications with other participants, when such activities or services are offered.

Therefore, we first ask that you review the Site generally, and that you specifically review the Privacy Policy Statement noted above carefully, as well as our Website Terms & Conditions of Use so that you are well-versed in our policies and practices. Please note that there is a section that allows for contacting us with any questions that you may have in respect to any of these.

Name of Child Applying to Access Site ______________________________________

Online User Name for Child _______________________________

Child’s Date of Birth ____________________

Name and Contact Information for Parent/Adult Legal Guardian ______________________________________________________

Date of Birth for Signing Parent/Adult Legal Guardian ____________________

Relationship to Child ___________________________


I, _______________________________ do hereby state that I am the Parent or Adult Legal Guardian of ______________________________ and that I have carefully read and reviewed the Privacy Policy Statement and Site User Agreements of PAX Programs Incorporated in relationship to its Web site. I specifically agree to these in reference to the gathering and using of individually identifiable information and consent to PAX Programs Incorporated allowing my child access to its Web site and to participate in communications and public forums, including, but not limited to, “chat rooms,” “bulletin boards,” email, submission of videos, and participating in such other online events and communications channels as may presently exist or later be developed as part of the operation and activities of the Web site.

SIGNATURE: _____________________________________________

DATE: _________________________

Disposition of Parental Consent Form

Once the information on this form has been completed, including the signature of the parent/or adult legal guardian of each child for whom consent is being given, then it can be returned by:

Faxing it to:

PAX Programs Incorporated

– or –

Mailing it to:

PAX Programs Incorporated
P.O. Box 2107
Monrovia, CA 91017

Legal Requests for Information

It is our Policy to respond to valid government and regulatory requests for information, court orders, or subpoenas issued by third parties.

This Notice is not an Offer or a Contract

This notice of Privacy Policy is for your information only – it is not an agreement or an offer and does not establish contract or other rights for you, the User. In particular, you have not created or entered into a contract by reading this notice and then submitting information. If you are a visitor, your use of PAX’s Site constitutes your consent to the collection and use of your information. Your rights with respect to these services are governed by the Site User Agreement(s) that you and/or your parent or legal guardian acknowledge you have read, understood, and accepted.

PAX Employees and Privacy Policies/Practices

PAX trains all PAX employees about the importance of privacy. It is PAX’s Policy to give access to your information only to those employees who require it to carry out the responsibilities of their jobs.

More Information

If you have any questions about this notice, please write to:

PAX Programs Incorporated
Attn: Legal Department
P.O. Box 2107
Monrovia, CA 91017