ICM The Change Movement LaRussell Concert Registration

Participant's Name*

First NameLast Name

Name of Program / Form*

For Data Analysis ONLY

Today's date*

MM/DD/YYYY

I am registering for participant (mark one):*

Adult (Self or Parent)Child

Participant's Email*

example@example.com

Participant's Phone Number*

Please enter a valid phone number.

Participant's Age:*

Age in years

Participant's Gender Identity:*

Participant ZIP Code of Residence*

US ZIP Code, 5 digits

Parent/Guardian Name (For Youth Registrants)

First NameLast Name

Parent/Guardian Phone Number (For Youth Registrants)

Please enter a valid phone number.

Participant's Ethnic Identity:*

Hispanic / LatinxNon-Hispanic / Non-LatinxUnsureDeclined to respond

Participant's Racial Identity. OK to check more than one:*

You checked "Asian American" above; would you please specify:*

Child's Phone Number (Optional)

Please enter a valid phone number.

Does the participant have any medical conditions?*

Please select YES or NO

If the participant has medical conditions (YES), please list the medical conditions and important information in this section:*

Emergency Contact Name*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Emergency Contact Relation to Participant*

Do you think your community has been impacted by environmental & transportation injustice?*

YESNO

Do you find it hard to get around in your community (transportation barriers, unsafe landscape for biking & walking, environmental pollution, and/or public transportation)

YESNO

Please describe the reasons behind your answers: *

Photo Consent I hereby grant permission to Innovative Change Makers for the use of the photograph(s) or electronic media images taken throughout the ICM The Change Movement LaRussell Concert Registration and Activities. I understand that I may revoke this authorization at any time by notifying in writing Brian Gatewood Sr. at bgatewood@innovativechangemakers.com. The revocation will not affect any actions taken before the receipt of this written notification. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.

The undersigned does also hereby give permission for the registered individual to ride in any vehicle designated by the Innovative Change Makers Facilitators while attending and participating in activities for the ICM The Change Movement LaRussell Concert Registration and Activities.

WAIVER AND RELEASE OF LIABILITY

I, the undersigned, am a person at least 18 years of age. I am the parent or guardian of the minor child named above as "Participant", and that child desires to voluntarily participate in the IICM The Change Movement LaRussell Concert Registration and Activities, organized by Innovative Change Makers.

Waiver and Release of Liability I hereby assume all responsibility and risk for any accidents, sickness, or other mishaps, including, but not limited to serious bodily injury that may result during the Program. In connection with the youth I have registered participation in the Program, I hereby waive all rights to any claim, cause of action, and/or the right to file a law suit against Innovative Change Makers, or against any of its affiliates, parent organizations, directors, officers, sponsors, employees, agents, volunteers, successors and assigns. I further release all such organizations and/or persons from any and all responsibility or liability of any nature whatsoever for any loss or damage to my person or property, including, but not limited to, personal injury sustained on or through the Program.

This Waiver of Release of Liability is binding upon my and my child’s personal representatives, trustees, heirs, successors, beneficiaries, relatives, next of kin or assigns and shall inure to the benefit of all organizations named herein as well as to their directors, officers, sponsors, employees, agents, volunteers, successors and assigns.

Confirmation BY ACKNOWLEDGING AND SUBMITTING FORM BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Participant or Parent's Signature*