Parental Consent Form

Please review, print out and complete the information below.  After completion of this form, please have it notarized, then mail it to: Netyab.com, 3501 E. 42nd Avenue, Suite 309, Anchorage, Alaska 99508.  We do not accept e-mails, copies, or  faxes with regard to this form.

I, __________________________, (Legal Guardian/Parent's First and Last Name) hereby certify that I am the parent and/or lawful guardian of __________________________. (Child's First and Last Name) I have read and agree to the Terms of Service and Privacy Policy of Netyab.com. I consent and agree that once my child is a member of Netyab.com, my child's use of your services will be subject to the Terms of Service and the Privacy Policy of Netyab.com. I authorize Netyab. com to register my child as a member using the following information:

(*) denotes the information is optional at the time of registration.

Print legible your child's first and last name: ________________ ________________
E-mail address: _____________________    
Do you want to show you e-mail on your profile page? Yes / No  (Circle One)
*Age: ______   *Gender: Male / Female  (Circle One) 

Please see Netyab.com's registration form for options on language, location, and Marital Status.
*Language: _________________   *Location: __________________
*Marital Status: _____________    

Note: Nicknames must be between 4 to 20 characters (use a-z and/or numbers)

Choose a Nickname:_________________ 
Alternate Nickname1:________________  Alternate Nickname2:_______________

There are no guarantees that your nickname or alternatives will be available at registration.  On the back of this form, you can list alternative nicknames by indicating with numbers which one you would prefer first. If by chance all of the nicknames you have provided are taken, we will have to start the processing of your parental consent form again.  So it is important that you list as many alternatives as possible.

I recognize that I can remove, and review my child's personal information at Netyab.com at any time. It is my responsibility as the parent and/or legal guardian to supervise my child while he or she is using Netyab.com's services. Also I understand that there may be updates to the Terms of Service and/or Privacy Policy at any given time. It will be my responsibility to view the updates on a periodic basis. 

I certify that the above information is correct to the best of my knowledge and I give my permission to Netyab.com to set my child's membership.

Signature of Parent ________________________
Date: __________		 Signature of Notoriety _____________________
Date: __________
   
Office Use Only:
Date Received: ____________     Date Entered:_____________  Status:_____________
Note: