Self-Exclusion Enrollment Form

Enrolls a patron in a voluntary self-exclusion program by capturing identity verification, photo consent, exclusion period, and acknowledgment of program terms.

Program Notice and Consent

• Program notice
  Self-exclusion is voluntary. By enrolling, you are requesting to be excluded from gaming access for the selected period. Your submission may be retained in an audit trail for compliance purposes.
• I consent to the collection and use of my personal information for self-exclusion enrollment
• I acknowledge that I have read and understand the self-exclusion program terms

Patron Identification

• Full name
• Date of birth
• Phone number
• Email address
• Government ID type
• Government ID last 4 digits
  Enter only the last 4 digits of the ID number for verification and record matching.

Exclusion Period

• Requested exclusion period
• Specify the exclusion period
• Requested effective date
  If your program has a mandatory waiting period, the effective date may be adjusted during review.

Photo and Verification

• Patron photo
  Upload a clear front-facing photo for identification and audit trail purposes.
• Supporting document
  Optional: upload any supporting enrollment document if required by your jurisdiction or venue policy.

Acknowledgment and Submission

• I understand that self-exclusion may restrict my access to gaming areas and related services for the selected period
• Signature
• Additional notes
  Use this field for any program-specific notes, interpreter assistance, or accommodation requests.