Proof of Consent Form – SMS Communication
Purpose of Consent
I, the undersigned, hereby provide my express written consent to receive and/or send SMS (text)
messages from:
Business/Organization Name: ____________________________________________
Phone Number(s) Used for Messaging: ____________________________________
Details of Consent
- I understand that by signing this form, I agree to receive SMS text messages, which may include
informational, transactional, or promotional content.
- Message and data rates may apply depending on my mobile carrier plan.
- Message frequency may vary.
- I understand that my consent is not a condition of purchase.
- I may withdraw my consent at any time by replying STOP to any received message or by providing
written notice to the business at: ____________________________________.
Participant Information
Full Name: ____________________________________________
Mobile Number: ________________________________________
Email (optional): _______________________________________
Address: ______________________________________________
Duration of Consent
This consent remains valid until I revoke it in writing or by following the opt-out instructions provided in
messages.
Acknowledgment
I confirm that I have read and understood the above, and I voluntarily consent to send and receive SMS
messages under the conditions stated.
Participant Signature: ___________________________Date: _______________
Printed Name: ____________________________________
Business/Organization Representative Signature: ___________________________Date: _______________
Printed Name: ____________________________________