The Myton Hospices | Self-Exclude Declaration

Gambling Commission - Licence Conditions and Code of Practice

If you feel you have a problem with gambling and would like to request that The Myton Hospices excludes you from all of its gambling related activities, including receiving gambling related marketing materials, you can simply complete and submit the form below.

I have a gambling problem and therefore wish to be excluded immediately from all of The Myton Hospices's gambling related activities, including receiving any gambling related marketing materials from The Myton Hospices, for a minimum period of:

Duration

Following our successful completion of your self-exclusion request:

Your chosen self-exclusion period will remain in force with The Myton Hospices, for a minimum of year(s).
The Myton Hospices will not send you any gambling related marketing materials, unless and until you specifically request us to do so.

Please ring the The Myton Hospices Lottery helpline on 01926 407902, if you wish to extend your chosen self-exclusion period (minimum 6 months extension).

Your details

Title

First name

Last name

Date of birth

Email address

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Main telephone number

Your address

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Address line 2

Address line 3

Address line 4

Town/City

County

Postcode

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I acknowledge my responsibility in ensuring adherence to this agreement. I acknowledge that the Promoter, its employees or agents have no liability or claims arising from my voluntary use of the gambling facilities provided.

Please tick the box to acknowledge.

Online self exclusion

Online self exclusion

Gambling Commission - Licence Conditions and Code of Practice

Your details

Your address

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