Evisum, Inc. Minor Student
Consent Form

(Use one form for each child)

This consent is page 3 of the Privacy Policy and is designed for use only with the Privacy Policy attached. If it is not attached, you are assuring Virtualology that you have read the policy and did not want to forward the whole document.

Mail to: Evisum, Inc., PO BOX 441, Bridgeville, PA, 15017

I have read the privacy policy found at Evisum, Inc. Privacy Policy. I understand that a copy of the total privacy policy may be found at our website at Evisum, Inc. Privacy Policy. The privacy policy may also be obtained by requesting it be mailed by writing to us at: Evisum, Inc., PO BOX 441, Bridgeville, PA, 15017

I HEREBY UNCONDITIONALLY GRANT MY PERMISSION AND CONSENT TO YOU TO COLLECT AND TRANSFER TO THIRD PARTIES (EDITING SPONSORS, JUDGES, ETC... SEE USES OF INFORMATION COLLECTED IN PRIVACY POLICY) ANY OF MY CHILD’S PERSONALLY IDENTIFIABLE INFORMATION AND CLASS WORK WHICH HE OR SHE MAY PROVIDE TO YOU FOR THE PURPOSE OF REVIEW, EDITING AND POSSIBLE PUBLICATION AT Evisum, Inc. AND ITS AFFILIATED INTERNET SITES. I HEREBY STATE AND AFFIRM THAT I AM THE LEGAL GUARDIAN OR PARENT OF THIS CHILD AND THAT I AM OVER THE AGE OF 18 YEARS OLD.

I HEREBY UNCONDITIONALLY GRANT MY PERMISSION AND CONSENT TO Evisum, Inc. THE unlimited publication (in total or edited) and broadcast, use, FOR THE incorporation into Evisum, Inc. websites, or other Evisum, Inc. mediums, of any submissions and that they may be used in any current or future advances in the state of communication that may be developed for virtualology publication and/or broadcasting.

I understand that I may revoke this consent by going to Evisum, Inc. Revocation Form, and printing the Revocation of Parental Consent Form, completing and signing it, and mailing it back to:

Evisum, Inc.
PO BOX 441
Bridgeville, PA, 15017

I understand that I may chose to have my child’s first name omitted from publication on the Evisum, Inc. web site by prominently stating this on my child’s submission next to their name. I understand that if an actual name is not used, a screen name including city, state, class name, class category (primary, secondary, college or some level in school) and school identifier must be provided. I understand that it is Evisum, Inc. Policy not Publish or Broadcast any minor student's last name on any Evisum, Inc. websites.

The following required information will be used for verification purposes and to issue the submission code.

Child’s name: _______________ Child’s screen name (No last names): _________________

Child’s Email address (optional) : ____________ Parents Email : ______________________

Parent/Legal Guardian name: ____________________________________

Address: ____________________________________________________________________

Teachers name: _______________________ Teacher’s Email: ____________________

School name: ___________________ School phone number: ______-- ________-- _______

School Address: ______________________________________

______________________________________

Parent/Legal Guardian Signature: ____________________________ Date: ____________

Note: The mailed version may not be as current as the web site version

I understand that the privacy policy may change from time to time. The most current form can be found at the website or by requesting a copy through the mail. I understand that my child can not register with the site and participate in the activities of the site where personally identifying information is collected unless and until I sign, date, complete and return this form to you.

A copy of the Parental Consent Form will be Emailed to the parent/guardian (if under 18 years old) and in all cases, e-mailed to the teacher with the Submission Code for that particular child. This may take several weeks to process.

I understand that by signing my name above I am giving permission for personally identifiable information about my child to be collected and transferred. I understand that the form I am signing was obtained from Evisum, Inc.. This form may have been provided to me by my child, but I am assuring you that the signature below is my own legal signature, that I am over the age of 18 years and that I am the legal guardian or parent of this child and reside in the immediate household of this child.

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Evisum Inc.^TM Privacy Policy