This document requires an action on your part in order to register your Child as a subscriber for any PDHI web site. Your consent is required before we will collect or maintain any personal information about your Child. If you choose not to accept these Terms, your Child may still access the non-interactive areas of this site, but will not be able to use those portions of the site that require registration or the collection of personal information.

Please read the Child Privacy Statement before giving consent. Once we receive this form, we will issue you a Parental Consent Password, which you can use to register your Child or you can give to your Child so he/she can register him/herself. We collect your Child's email address, date of birth, gender, and information concerning a specific health related condition and medications. We also track statistical information that helps us enhance your interactive experience on our web site. Information given to us is stored on our secured servers with policies and procedures to maintain the safety and security of that information.

By signing this Parental Consent Form, I acknowledge and agree that:

1. I have read an understood the Terms of Use and the Privacy Policy and the Child Privacy Statement, for the web sites operated by PDHI,
2. to the extent that I have had questions concerning any of those policies or statements, I have contacted PDHI and those questions have been answered to my satisfaction,
3. I am the Child's parent or legal guardian with full right to consent to permit the Child to use the web sites,
4. I consent to my Child's use of the web sites and to the collection and maintenance of personal information about my Child at the web site in the manner described in the Privacy Policy, Terms of Use and Child Privacy Statement, and
5. My Child and I will be bound by the terms of the Terms of Use, Privacy Policy and the Child Privacy Statement.

Please complete the following information:

Child's email address: (Username when registering with the site)
Child's date of birth:
Parent's full name:
Parent's e-mail address:
Other means of contacting the parent: (optional)
Parent's signature:
Date:

How to get your consent to us
Complete the form, print it out, sign it, and then fax or mail it to PDHI at Fax: (515) 277-1376, or