To conform to COPPA guidelines and for the protection of minors, this form should be completed to allow minors under the age of 13 years of age to have full access to the below listed website. It should be completed by an authorized parent or caregiver and returned to Mistic Media to be considered valid.

Return this form completed and signed to:

Mistic Media

667 Poppy Circle

Vacaville, CA 95687

United States


For more information please contact [email protected].

Under Aged Account Holders Details


Account Username: ____________________________________________________________________

Registered Email Address: _______________________________________________________________

Website / Domain Name / URL: __________________________________________________________

Parent/Caregiver Details


Full Name: ____________________________________________________________________________

Address: ______________________________________________________________________________

State: ________________________________________________________________________________

Postcode: _____________________________________________________________________________

Country: ______________________________________________________________________________

Contact Telephone Number: _____________________________________________________________



I, hereby give my child permission to have full access to the above listed website.

In addition, I understand and agree:

         that I am responsible for the monitoring and safety of the accountholder; and

         that it is my responsibility to ensure the accountholder complies with any and all terms / rules / guidelines in place, including directions from authorized staff members representing Impulse Communications Inc. ; and

         to not hold liable Impulse Communications Inc. for any harm or damages as a result of my consent; and

         I am authorized to complete this form on behalf of the accountholder; and

         this form is complete and done so accurately; and

         this is a legally binding document.


Parent / Caregiver Full Name: ____________________________________________________________

Parent / Caregiver Signature: ____________________________________ Date: __________________