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Run: Self-Exclusion Enrollment Form

Enroll a patron in a voluntary self-exclusion program with identity verification, exclusion period selection, photo upload, and signed acknowledgments. Use i...

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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 (required)

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.

Yes No N/A

I understand the self-exclusion terms and consequences (required)

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.

Yes No N/A

Patron Identification

Full Name (required)

Date of Birth (required)

Used only for identity matching and age verification where required.

Government ID Type (required)

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 (required)

Requested Start Date (required)

If not approved immediately, the effective date may be adjusted according to program rules.

Scope of Exclusion (required)

Identification Photo

Current Photo (required)

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 (required)

Yes No N/A

I understand that property access, marketing contact, and account privileges may be restricted under the program (required)

Yes No N/A

Patron Signature (required)

Signature confirms the accuracy of the information provided and agreement to the self-exclusion terms.

Signature Date (required)

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