Last updated 2/17/2006

sprousebros.com

Name of Child _______________________________________________

Child's eMail Address __________________________________________________

Age of Child ______

Parent's Name ______________________________________________________

Parent's eMail Address ______________________________________________

Parent's Postal Address _______________________________________________

Check one in each of the following statements:

I have /_/ have not /_/ reviewed and understand your online privacy protection policy which is available at http://www.sprousebros.com/notice_to_parents

I consent /_/ do not consent /_/ to your collection, use and maintenance of personally identifiable information from and about my child.

I consent /_/ do not consent /_/ to your disclosing personally identifiable information about my child to third parties.

Dated: ________________

Signature ______________________________________

Please mail back to us at:

Dualstar Online
attn: SprouseBros.com Privacy Coordinator
3760 Robertson Blvd.
Culver City, CA 90232