INSTRUCTIONS: Please review and complete the information below. Print out this page, sign your name at the bottom of the form and fax it to The Charlotte Weekly at 704-849-2504. When The Charlotte Weekly receives and processes your consent form, we will activate your child's account. If you have any additional questions, please feel free to call us at 704-849-2261.

I, ________________, hereby certify that I am the parent and/or lawful guardian of ________________.

My child's Account Identity is _____________. I understand and agree than when my child registers with The Charlotte Weekly to use its services or participate in its surveys, contests or games, The Charlotte Weekly, or its authorized agents, may collect and maintain certain personal information about my child, including:

·  First and last name

·  Gender

·  Parent's e-mail address

·  Birthdate

·  Telephone number

I also understand and agree that if my child registers with The Charlotte Weekly to win a prize, The Charlotte Weekly, or its authorized agents, may collect my child's shipping address in addition to the above- described information.

I further understand and agree that the above-described information will not be disclosed to third parties unless The Charlotte Weekly has a good faith belief that it is reasonably necessary to comply with the law or to protect the interests of The Charlotte Weekly or others; except that such information may be provided to authorized third parties for the purposes of providing the services available on The Charlotte Weekly site or of awarding prizes.

I have read and reviewed the above and The Charlotte Weekly Privacy Policy and I give my permission for The Charlotte Weekly to collect, use and disclose personal information about my child in accordance with the terms stated therein.