REVOCATION OF PARENTAL CONSENT FORM

To: Vic Firth, Inc.
65 Sprague Street
Boston, MA 02136
Attention: Andrew Tamulynas

Date: ____________________

I understand that information about the activity of visitors to www.vicfirth.com is automatically provided to Vic Firth, Inc. when children and adults sign on. It is used by Vic Firth, Inc. for internal review in aggregate and non-personally-identifiable form. E-mail addresses and other personally identifying data about visitors is known to Vic Firth, Inc. only when voluntarily submitted or posted by visitors to www.vicfirth.com. Vic Firth, Inc. uses personally identifying data provided by a visitor only in connection with his or her use of the site and for Vic Firth, Inc. family promotion, planning and inventory purposes and will not disseminate such data to anyone outside of Vic Firth, Inc. In addition, Vic Firth, Inc. sometimes uses e-mail addresses and other personally identifying information to respond to visitors who communicate with you. For example, Vic Firth, Inc. directs e-mail to visitors who provide you with their e-mail addresses for specific purposes such as responding to an inquiry or notifying users of promotions.

I understand that industry standards for children's sites on the World Wide Web require that I provide to the owner/operator of the web site, an informed consent, on behalf of my child or the child for whom I act as legal guardian, before you may collect any personally identifiable information from the child which information may include but not be limited to his or her name, mailing address, e-mail address, telephone number, nickname, or Internet name, as well as products he or she likes to play with or would like to receive information about.

Parental Consent Previously Granted
I understand that I, or another parent in this household, previously granted to you -- by the return to you of a verifiable Parental Consent Form -- a parental consent enabling my child to register with the site, join any clubs on the site, and proceed into certain areas of your Internet site where such personally identifiable information may be requested or collected by you.

Revocation of Consent To Collect & Transfer Certain Information Specified Below
I hereby confirm to you that the signature below is my own true and accurate signature and I am at least 18 years of age. I hereby revoke the parental consent previously granted for you to collect and share with other parties the information I check off below as this child's parent, legal guardian, or most responsible adult figure above the age of 18 residing in his or her household. You may collect and share with other parties all other information not checked off below.

I understand that I may reinstate a Parental Consent at any time by going to www.vicfirth.com and printing and returning to Vic Firth, Inc. a Parental Consent Form.

All information concerning the child provided below is supplied only for purposes of verification of this Form and Vic Firth, Inc. will make no use of it for any other purpose.

Child's name: ________________________

Child's age: _________________

"Parent" name [please print carefully or type]: ___________________________________

Consent revoked for (circle all that apply):
Name
Mailing Address
E-Mail Address
Screen Name
Phone Number
Product Preferences
Thoughts & Opinions
Information about Child's Household

"Parent" Signature: _________________________

Date: ______________

Please return this Parental Consent Form promptly by mailing to the above street address, or by faxing to Vic Firth, Inc. at 781-326-1273. Vic Firth, Inc.

 

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