• PART 1

  • PERSONAL INFORMATION

  • Personal Information

  • We are sorry, but you have to be at least 18 years old to fill out this form. If you are under the age of 18, please have your parent or guardian fill out this form for you. 

  • We are sorry, but only the child's parents or guardians are authorized to fill out this form on the child's behalf. Please contact the child's parents or guardians and have them complete this form. Thank you.

  • Parent or Guardian's Information

    Please provide your contact information
  • Format: (000) 000-0000.

  • Gamer's Information

    Please provide your contact information
  • Format: (000) 000-0000.

  • PART 2

  • VIDEO GAME INFORMATION

  • Video Game Information

  • Gaming Console Information

  • Xbox Gaming Questions

  • Provide the Gamer's Xbox Gamertag(s) and email address(es) associated with the gamers Xbox account?

  • PlayStation Gaming Questions

  • Provide the Gamer's PSN ID(s) and email address(es) associated with the Gamer's PlayStation account(s)?

  • Nintendo Switch Gaming Questions

  • Provide the Gamer's Nintendo Switch username(s) and email address(es) associated with the Gamer's Nintendo Switch account(s)?

  • Gaming Subscription Questions

  • Video Games

  • Select the videos games the Gamer plays or has played for more than 50 hours:

  • Gaming History

  • For each game selected, provide the following if applicable:


    1. The year the Gamer started and stopped playing the game;

    2. The average amount of hours the gamer played per week.

    3. The amount the Gamer has spent on in-game content such as loot, level up options, rewards, badges, additional game content, etc;

    4. The method of payment used to make in-game purchases.

    • Minecraft 
    • Minecraft

      Minecraft

    • Roblox 
    • Roblox

      Roblox

    • Fortnite 
    • Fortnite

      Fortnite

    • Call of Duty Series 
    • Call of Duty Series

      Call of Duty Series

  • PART 3

  • INJURIES AND MEDICAL INFORMATION

  • Video Games Related Injuries

  • Negative Gaming Symptoms

  • Gaming Injuries and Diagnoses

    • Medical Provider 

    • Medical Provider Information

    • Provide:

      (1) The Contact Information of the Medical Provider(s) Who Diagnosed or Treated the Gamer; and

      (2) Date of Diagnosis(es)

    •  - -
    • Format: (000) 000-0000.
    • Medical Provider 1 

    • Second Medical Provider Information

    •  - -
    • Format: (000) 000-0000.
    • Medical Provider 1 

    • Third Medical Provider Information

    •  - -
    • Format: (000) 000-0000.

  • Please upload any documentation regarding the diagnosis and treatment of the Gamer's injuries:

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  • Medical Treatments and Plans

    • IEP Treatment 

    • Provide the name and address of the school and approximate years that the Gamer's Individualized Educational Plan (IEP) has been in place:

    •  - -
    •  - -
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    • Counselor Treatment 

    • Please provide the contact information of the psychiatrist, counselor, or other medical provider(s) who treated the Gamer injuries and the dates of treatments:

    • Format: (000) 000-0000.
    •  - -
    •  - -
    • Counselor Treatment 

    • Please provide the contact information of the psychiatrist, counselor, or other medical provider(s) who treated the Gamer injuries and the dates of treatments:

    • Format: (000) 000-0000.
    •  - -
    •  - -

  • Please upload any documentation regarding the Gamer's Treatment:

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  • PART 4

  • Litigation and Criminal History

  • Should be Empty: