District Of Columbia
Name of parent(s)/legal guardian(s) & relationship
Parent/Guardian’s phone numbers
What types of activities does your family like to do together?
What types of things would you like to do as a family that you currently do not?
Household/Family Income Level
Less than $10,000
$10,000 - $29,999
$30,000 - $59,999
$60,000 - $89,999
$90,000 – $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 or more
Race/Ethnicity of Child (for demographic purposes only)
Permission Form and Photo Release
Variety’s Discover Program events are for all members of the IMMEDIATE family of the child with a physical or developmental special need (i.e., parents and siblings who live in the home).
Please list all members of the household (children and adults) who may attend Variety’s Discover Program events:
Permission/Waiver: I hereby grant permission for my child(ren) to participate in Variety’s Discover Program events. I
recognize that unanticipated situations and problems can arise during activities that are not reasonably within the control
of Variety staff, including volunteers. I therefore agree to release and hold harmless Variety – the Children’s Charity of
Wisconsin, its agents, officers, employees, and volunteers from any and all liability, claims, suits, demands, judgments,
costs, interest and expense (including attorney’s fees and costs) arising from such activities, including any accident or
injury to the child or myself and the costs of medical services.
Photo Release: I give permission to Variety – the Children’s Charity of Wisconsin to use my or my child(ren)’s name,
and/or any photograph or image taken of me or my child(ren) during Variety Discover Program events, whether recorded
or transferred to video tape, slides, photographs, internet, or any other form of media for use in any promotional materials,
publications and/or press releases. I understand that I will not be compensated for my time or the rights to use the
image(s) or its copyright or copyright issues. I agree that it is not necessary for Variety or anyone else to contact me prior
to releasing any information authorized by this release. I agree to release, on behalf of myself or my child(ren), Variety
from and against any and all claims, of any type, which arise from or are related to Variety’s use, distribution or disclosure
of any photographs, films, videotapes, electronic recording or other information regarding myself or my child(ren).