Participant Name *

First Name

Last Name

Participant Phone *

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Participant's Gender *

Male

Female

Non-binary

Prefer not to say

Please provide the participant's home address. *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you registering someone who is under the age of 18? *

Yes

No

If you are registering someone who is under the age of 18 please provide a name for a parent/guardian.

First Name

Last Name

If you are registering someone who is under the age of 18 please provide a phone number for a parent/guardian.

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Waiver: *

PLEASE READ CAREFULLY. THIS DOCUMENT AFFECTS YOUR LEGAL RIGHTS AND IS LEGALLY BINDING. BY SIGNING THIS AGREEMENT YOU ARE RELEASING NW GOLDBERG CARES FROM ALL LIABILITY AND FOREVER GIVING UP ANY CLAIMS THEREFOR. ASSUMPTION OF RISK I, in my legal capacity as myself or as parent/guardian of the minor named below (“Minor”), acknowledge and agree that any use of NW Goldberg Cares facilities, services, equipment and premises (“Facilities”) and any participation in NW Goldberg Cares programs and activities (“Programs”) comes with inherent risks including, but in no way limited to: (1) moderate and severe personal injury, (2) property damage, (3) disability, (4) death, and (5) sickness or disease including, without limitation, COVID-19. I voluntarily, for myself and Minor, accept and assume full responsibility for these risks as well as any and all other risks of the use of Facilities and participation in Programs. I agree that I have full knowledge of the nature and extent of all such risks and am not relying on all such risks being described in this document. WAIVER, RELEASE, INDEMNIFICATION & COVENANT NOT TO SUE In consideration of myself or Minor’s use of Facilities and participation in Programs I, in my legal capacity as parent/guardian of Minor, agree on behalf of myself and Minor that NW Goldberg Cares, its officers, directors, agents, employees, volunteers, insurers and representatives (“Releasees”) will not be liable for any personal injury, property damage, disability, death, sickness or disease incurred by Minor, however occurring including, but not limited to, the negligence of Releasees. I understand that Minor and I will be solely responsible for any loss or damage, including personal injury, property damage, disability, death, sickness or disease sustained from the use of Facilities and participation in Programs. I further agree, in my legal capacity as myself or as the parent/guardian of Minor, on behalf of Minor, myself, and any and all legal successors and proxies, to release and HEREBY DO RELEASE, WAIVE AND COVENANT NOT TO SUE Releasees from any causes of action, claims, suits, liabilities or demands of any nature whatsoever including, but in no way limited to, claims of negligence, which Minor, myself, and any and all legal successors and proxies may have, now or in the future, against Releasees on account of personal injury, property damage, disability, death, sickness, disease or accident of any kind, arising out of or in any way related to the use of Facilities or participation in Programs, whether that participation is supervised or unsupervised, however the injury or damage occurs, including, but not limited to, the negligence of Releasees. In further consideration of the use of Facilities and participation in Programs, I, in my legal capacity as myself or parent/guardian of Minor, agree on behalf of myself and Minor to INDEMNIFY AND HOLD HARMLESS Releasees from any and all causes of action, claims, demands, losses, suits, liabilities or costs of any nature whatsoever, including claims of negligence, arising out of or in any way related to the use of Facilities and participation in Programs. PHOTO RELEASE I hereby irrevocably consent to and authorize the use and reproduction by NW Goldberg Cares, or anyone authorized by NW Goldberg Cares, of any and all photographs taken of myself or my child, negative or positive, for any purpose whatsoever without compensation to me. All negatives and positives, together with the print, shall constitute NW Goldberg Cares’s property, solely and completely.

Please check this box as a virtual signature.