Child's Name: Age: Wheelchair: -- Yes No
Disability:
Address:
City: State: Pennsylvania Alabama Alaska Arkansas American Samoa Arizona California Colorado Connecticut Disasp:TableRowict Of Columbia Delaware Florida Federated States Of Micronesia Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jeresy New Mexico Nevada New York Ohio Oklahoma Oregon Rhode Island South Carolina South Dakota Puerto Rico Palau Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming Zip Code:
Home Phone: () - Alternative Phone: () -
Email Address:

Others Attending:

Parent: Age: Has Disability: -- Yes No
Parent: Age: Has Disability: -- Yes No
Siblings #1: Age: Has Disability: -- Yes No
Sibling #2: Age: Has Disability: -- Yes No
Sibling #3: Age: Has Disability: -- Yes No
Sibling #3: Age: Has Disability: -- Yes No

As my child’s parent/guardian, I understand, accept and agree that Variety’s various programs may result in publicity for educational and promotional purposes; and, therefore, irrevocably give my consent to Variety to use and publicize my child’s name and photo in any videotape, picture film in which he/she appears, and/or audio recordings of her/his voice, including television, that may be used by Variety the Children’s Charity, its assigns or successors, now or in the future.  Furthermore, I hereby consent that such photographs, films, recordings, and tapes from which they are made, shall be the property of Variety the Children’s Charity, its assigns and successors, and they shall have the right to sell, duplicate, reproduce and make other uses of such photographs, films, recordings, and tapes free and clear of any claim on my part and forever discharge Variety the Children’s Charity from and against any and all claims, of any type, which arise from or related to Variety’s use, distribution, or disclosure of any photos/recordings/videotapes or other information regarding my child.  I waive the right to inspect publications or products that include my child prior to their release.