Your Name *

First Name

Last Name

Your Phone Number *

(###)

###

####

Child's Name *

Please note - you must complete a separate registration for each child that you are registering.

First Name

Last Name

Emergency Contact *

Please provide an additional contact in the event that we cannot reach you.

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

Checkbox *

Program Staff: All staff, interns, and volunteers associated with the PLAY NW GOLDBERG Program (“Program”). Organizations: All representatives, board members, secretaries, assistants and volunteers associated with NW Goldberg Cares. I, the undersigned parent/guardian of the registrant child, a minor, agree that the registrant child will abide by the Program’s rules. The undersigned acknowledges that in consideration of the registrant child being allowed to participate in sports activities facilitated by the Program Staff on behalf of NW Goldberg Cares, the undersigned hereby agrees, on behalf of the registrant child, the undersigned and his or her heirs, legal representatives, guests, and invitees, that: 1) The undersigned hereby accepts and assumes any and all risks resulting from attendance and participation of the registrant child in such activities and any injuries which occur from such activities or presence at facilities where such activities take place; 2) The undersigned hereby further acknowledges and recognizes that sports activities may possibly result in injury and assume this risk on behalf of the registrant child; 3) The undersigned hereby waives any and all claims of liability that the undersigned or the registrant child may have against the Program Staff or NW Goldberg Cares for any personal injury, damage or any other possible claims arising from registrant’s participation in the Program, including but not limited to any participation in any sports activities or the use of any sports facilities utilized during the Program; 4) The undersigned hereby grants NW Goldberg Cares the right to photograph or videotape the undersigned and/or registrant child in connection with the Program conducted by NW Goldberg Cares. The undersigned further authorizes NW Goldberg Cares its assigns and transferees to copyright, use and publish the same in print and/or electronically for purposes associated solely with  Motor City Grounds Crew/NW Goldberg Cares/360 Detroit/Life Remodeled/Woodbridge Neighborhood Development.

Please check this box as a virtual signature.