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Run: Self-Exclusion Enrollment Form

A Self-Exclusion Enrollment Form for enrolling a patron in a voluntary exclusion program, capturing identity verification, photo consent, exclusion period, a...

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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 (required)

Yes No N/A

I acknowledge that I have read and understand the self-exclusion program terms (required)

Yes No N/A

Patron Identification

Full name (required)

Date of birth (required)

Phone number

Email address

Government ID type (required)

Government ID last 4 digits (required)

Enter only the last 4 digits of the ID number for verification and record matching.

Exclusion Period

Requested exclusion period (required)

Specify the exclusion period (required)

Requested effective date (required)

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

Photo and Verification

Patron photo (required)

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 (required)

Yes No N/A

Signature (required)

Additional notes

Use this field for any program-specific notes, interpreter assistance, or accommodation requests.

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Email (required)

Your name (optional)

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