Age of Child Participants:4-14 year-old boys and girls
Number of Child Participants: 64
Number of Adult Volunteers/Coaches: 35


Program Days/Hours: Saturdays, 10AM - 1PM
2016 Program Dates: July 9 – August 27, 2016, 8-weeks
Program Location: Pier 40 Rooftop Field - 353 West Street, New York, NY 10014

Program Location Address:
Transit Information: 1 subway line to Houston Street; M8, M21 buses
Additional Information about Pier 40:
Driving Directions: click here


Note: we prefer that you complete the form online for each child, but you may also download it via this link
and either fax or mail it to us following the instructions on page 2.

Fields with * are required.

Will your child require (note: a program volunteer will pick up your child and/or drop off your child by public transit; Transit aid will provide a pass or funds for you to take your child yourself)?


In exchange for my and/or my child's being allowed to view and/or participate in Pickup Soccer YOUTH OUTREACH's 'Kids Classic/Free Play 2016!' organized and/or sponsored by Pickup Soccer YOUTH OUTREACH, Inc., I understand and agree:

"Pickup Soccer YOUTH OUTREACH, Inc.," (hereinafter jointly referred to as "Pickup Soccer YOUTH"), a recreational soccer organization, and its subsidiaries, affiliates, directors, officers or volunteers assume no responsibility or liability, direct or indirect with respect to my or my child's participation in, Pickup Soccer YOUTH's 'Kids Classic/Free Play 2016!

Soccer is potentially hazardous, and the risk of injury is significant, including the potential for permanent paralysis and death, and while particular rules and equipment may reduce this risk, the risk of serious injury, including death, does exist. I assume all risks, including but not limited to, falls, contact with other participants, damage to any of my/my child's own sports equipment, injury to spectators caused by my actions, effects of the weather, and conditions of the field.

I grant permission for my child to be filmed or recorded during Pickup Soccer YOUTH's 'Kids Classic/Free Play 2016!' and waive all rights in any film or recording made thereof. I hereby grant Pickup Soccer YOUTH, its subsidiaries, affiliates, directors, officers or volunteers the perpetual and irrevocable right to use my child's picture, portrait, or photograph for all purposes and in all media including advertising, trade, promotion, exhibition, or any other lawful purposes and hereby release and agree to hold harmless Pickup Soccer YOUTH, its subsidiaries, affiliates, directors, officers or volunteers from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form in the recording or processing of the photographs, films and/or videos toward the completion of the finished product. I hereby waive any claims I may have based on any usage of the photographs, films, and/or videos or works derived therefrom.

I hereby release from and waive any claims against Pickup Soccer YOUTH resulting from my and/or my child's participation in Pickup Soccer YOUTH's 'Kids Classic/Free Play 2016!'. I understand that, in exchange for my participation, and by signing this Liability Release and Waiver, I am expressly waiving my right and my child's right to bring a claim of any kind against the group directly or indirectly for conducting or being involved in any way with PSNYC.

I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releases or others and assume full responsibility for my participation.

(Clear signature)
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