Voluntary self-exclusion
Subscription form

First name

Family name

Address

I, the undersigned, request and authorize the Montreal Hippodrome (Attractions Hippiques) to take the necessary measurements to prevent me from having access to the Hippodrome and Hippoclubs in the area.

If a Paritel account is currently open under my name, I ask that the account be closed on reception of this form, and the balance of the account paid to me by cheque in my name.

I understand that if I ask to have the account reopened, the request will be rejected for a period of at least twelve (12) months with the possibility of a permanent and irrevocable cancellation.

In order to respect and comply with my request for self-exclusion, I accept and understand that my name, address, and any other information which makes it possible to identify me, is registered and shared with the Hippodrome and Hippoclub security services.

I release the Montreal Hippodrome (Attractions Hippiques) of any responsibility in the event that I, in some way, infringe upon this self-exclusion contract to which I voluntarily subscribed. I also give up exercising any recourse in this respect.

I ask that my request be:
in force for a period of 12 months
permanent and irrevocable