Celtic Radio Community: COPPA Permission Form

Instructions for a parent or guardian

Please print this form out, complete it and fax it to the number specified (if present) or mail to the mailing address below.


Fax Number:

Mailing Address:
Att: Paul MacArthur
COPPA Registration
CelticRadio.net
24 Central Street
Braintree, MA 02184

Choose a Member Name
3 - 32 letters and/or numbers only.
 
Choose a Password
Passwords must be between 3 and 32 characters long.
 
Your email address
You will need to enter a real email address.
 

Please sign the form below and send to us.

I understand that the information that the child has supplied is correct. I understand that the profile information may be changed by entering a password and I understand that I may ask for this registration profile to be removed.

Parent / Legal Guardian FULL name  
Relation to child  
Signature  
Email Address  
Phone Number  
Date