RCT*Mart Forums: 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: n/a

Mailing Address:
RCTmart.com COPPA Compliance
c/o Brad Bergman
445 East Bush Street
Fort Bragg, CA 95437

Enter your desired log in username  
Enter your 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  
Email Address  
Phone Number