Lottery Self Exclusion Form

We understand that you may, for personal reasons, wish to exclude yourself from the St Rocco’s Lottery and will make every effort to assist you to do so and to offer further advice at your request.

To exclude yourself from the St Rocco’s Lottery please complete the form below, which will be held by St Rocco’s Promotions Ltd for the duration of the agreement.

On receiving a completed Self-Exclusion Form we will exclude you from the St Rocco’s Lottery for a minimum period of 6 months from the agreement date.

During the exclusion you will not receive any marketing materials related to gambling activity from St Rocco’s Hospice (which includes, but is not limited to lottery and raffle).

At the end of the agreement you can review your exclusion with the Lottery Manager and choose to either extend or end the agreement.



Please exclude me from your Lottery with immediate effect and do not make any direct contact with myself during my exclusion period.

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