Parental App Blocking Request Form
Submit your request to block specific applications on your child's device.
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Mother
Father
Legal Guardian
Other
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child's Full Name
*
First Name
Last Name
Child's Age
*
Device Type
*
Please Select
Smartphone
Tablet
Computer/Laptop
Other
Device Operating System
*
Please Select
iOS
Android
Windows
MacOS
Other
List the applications you wish to block (please specify app names)
*
Reason for Blocking These Applications
*
Preferred Blocking Duration
*
Please Select
Indefinitely
1 week
1 month
Until further notice
Additional Comments or Special Instructions (optional)
Date of Request
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Signature
*
Submit Request
Submit Request
Should be Empty: