5th Annual “Happy Haunts” Halloween Party
Online Registration Form

Saturday, October 15, 2011
11:00 a.m. – 2:00 p.m. 
Bayer MaterialScience (Robinson Twp.)
Freddie’s Café – Building 6, 100 Bayer Road
Pittsburgh, PA 15205


Please Note - It is our desire to accommodate as many Variety children as possible; therefore, due to space limitations, we ask that you limit RSVPs to your child, their siblings and two adults per family.  PRE-REGISTRATION IS REQUIRED.


Child's Name: Age: Wheelchair:
Disability:
Address:
City: State: Zip Code:
Home Phone: () - Alternative Phone: () -
Email Address:

Others Attending:

Parent: Age: Has Disability:
Parent: Age: Has Disability:
Siblings #1: Age: Has Disability:
Sibling #2: Age: Has Disability:
Sibling #3: Age: Has Disability:
Sibling #3: Age: Has Disability:

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.

Electronic Signature: