Parental Consent Form

As your child/ward is under 18 years of age, we request that you complete this form to confirm that you have given
him/her permission to become a member of the Go Rewards Loyalty Program (the “Program”). Kindly read and
understand the information contained in the Program Terms and Conditions, Privacy Policy, and this Parental Consent
Form. Thereafter, please proceed to complete, sign, and return a scanned copy or photo of the signed form to [X].

Inform at ion of t he Minor

Last Nam e
First Nam e
Middle Nam e
Dat e of Birt h (MM/ DD/ YYYY) / /
Cit y Province
Em ail Address
Mobile Num ber
Always keep up- t o- dat e wit h t he lat est from GoRewards! Would you like t o receive updat es on personalized offers and prom os?
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Inform at ion of t he Parent / Guardian

Last Nam e
First Nam e
Middle Nam e
Dat e of Birt h (MM/ DD/ YYYY) / /
Cit y Province
Em ail Address
Mobile Num ber
Go Rewards Mem bership Num ber (opt ional) - - -

In my capacity as the parent/legal guardian of the minor named above, I hereby agree, authorize, and provide my
consent for my child/ward to enroll in and become a member of the Program.

I hereby certify and warrant that I am the parent/legal guardian of the abovenamed minor; that I am at least eighteen
(18) years of age and fully competent to sign this form; that I have read, understood, and agree to be bound by the
Program Terms and Conditions and Privacy Policy; and that the information I had provided in this Parental Consent
Form is true, complete, and accurate.

Parent/ Legal Guardian’s Full Name and Signature Date