Self-Exclusion Enrollment Form

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

Program Notice

• Self-Exclusion Program Notice
  This form is used to enroll a patron in a voluntary self-exclusion program. Information collected will be used only to verify identity, administer the exclusion, and support compliance and audit trail requirements.
• Consent to collect and use my personal information for self-exclusion administration
  By checking this box, you consent to the collection and use of the personal information and photo provided on this form for identity verification, exclusion enforcement, and compliance recordkeeping.
• I understand the self-exclusion terms and consequences
  I understand that self-exclusion may restrict my access to gaming areas, promotions, and related services for the selected period, and that violations may result in removal or other actions permitted by program rules.

Patron Identification

• Full Name
• Date of Birth
  Used only for identity matching and age verification where required.
• Government ID Type
• Government ID Last 4 Digits
  Optional. Use only if needed to match the identity record.
• Phone Number
  Optional contact number for enrollment follow-up and confirmation.
• Email Address
  Optional email for confirmation and program communications.

Address and Contact Details

• Street Address
• City
• State / Province
• Postal Code

Exclusion Period

• Exclusion Period
• Requested Start Date
  If not approved immediately, the effective date may be adjusted according to program rules.
• Scope of Exclusion

Identification Photo

• Current Photo
  Upload a clear, recent photo of the patron. This will be used only for self-exclusion administration and enforcement.
• Photo Taken Date
  Optional. Helps confirm the photo is current.

Acknowledgment and Signature

• I understand the exclusion may not be revoked before the end of the selected period, except as allowed by program rules
• I understand that property access, marketing contact, and account privileges may be restricted under the program
• Patron Signature
  Signature confirms the accuracy of the information provided and agreement to the self-exclusion terms.
• Signature Date