Screen Time Permission Revocation Request Form
Use this form to request the revocation of a child’s screen time permission. Please complete all fields to ensure your request is processed promptly.
Parent/Guardian Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Child’s Full Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Parent
Legal Guardian
Other
Date Permission Revocation Should Take Effect
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Revocation
*
Submit Request
Should be Empty: