Self-Exclusion Enrollment Form

This template is used to collect a patron’s voluntary request to self-exclude from one or more gambling or gaming facilities. It organizes the notice, identity fields, exclusion period, photo, supporting documents, and signed acknowledgment into a single enrollment record. Use it when the program requires a documented request before exclusion takes effect.

The patron should complete the request, then a trained staff member or program administrator should verify identity and review the submission. If your process allows assisted intake, the staff member should still preserve the patron’s own acknowledgment and signature. Keep an audit trail of who reviewed and approved the enrollment.

It is typically used once per enrollment event, and again only if the patron renews, extends, or changes the exclusion scope. Some programs also use a separate re-entry or removal form when the exclusion period ends. Do not reuse the same record for multiple exclusion periods unless your policy explicitly allows amendments.

Only collect the fields needed to identify the patron, confirm the request, and administer the exclusion. Legal name, date of birth, ID verification, exclusion period, and consent are usually required, while contact details may be optional unless your program needs them for notices. Avoid collecting extra PII that the program will not use.

Usually no, because self-exclusion programs need identity verification, a photo, and a signed acknowledgment to enforce the request. If your jurisdiction or facility offers an anonymous pre-screening step, that should be a separate intake form, not this enrollment form. This template is designed for verified enrollment, not anonymous reporting.

Treat the form as a sensitive PII workflow and limit collection to what is necessary for the exclusion program. Use clear consent language, explain how the photo and ID will be stored and used, and keep access restricted to authorized staff. If your program is regulated by gaming authorities or local law, align the retention and notice language with those rules.

Use a controlled field for the exclusion period so the patron chooses from approved durations rather than entering free text. Facility scope should be a multi-select or conditional field that matches your actual locations, brands, or property groups. This prevents ambiguous enrollments and makes enforcement easier at the door or in the system.

Common integrations include identity verification, document storage, case management, and facility access or watchlist systems. If your operation uses a centralized exclusion database, map the form fields to that record so the enrollment can be exported without retyping. Keep the integration limited to the minimum necessary data set.

A structured form reduces missing fields, inconsistent wording, and unreadable signatures. It also creates a cleaner audit trail, supports validation and conditional logic, and makes it easier to route the request to the right reviewer. Compared with ad hoc intake, it is easier to enforce the same process every time.