Virtualology Revocation Form

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Evisum, Inc. Revocation Form

Mail to:

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

Date:

I have read the privacy policy found at Evisum, Inc. ™ Privacy Policy. I understand that the privacy policy may change from time to time.

I understand that my child could not register with the site and participate in the activities of the site where personally identifying information is collected unless and until I or another parent or legal guardian sign, date, complete and return the parent consent form to you. I also understand that I or another parent or legal guardian previously granted permission for my child to give personally identifiable information by signing and returning the parental consent form

REVOCATION OF CONSENT TO COLLECT AND TRANSFER CERTAIN INFORMATION LISTED BELOW

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.

I HEREBY REVOKE the parental consent previously granted for you to collect and share with third parties all information.

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

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

The following information is being requested for use for verification purposes.

Child’s name: ________________________________________________

Child’s screen name: ___________________________________________

Child’s Email address: __________________________________________

Parent/Legal Guardian name: ____________________________________

Address: ____________________________________

____________________________________

Parents Email (optional): ______________________

Teachers name: _____________________________________

School name: _______________________________________

Teacher’s Email: _____________________________________

School Address: ______________________________________

______________________________________

School phone number: ______-- ________-- _________

International phone code, if applicable: _____

Parent/Legal Guardian Signature: ________________________________

Date: ____________

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Evisum, Inc. Revocation Form

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