Satellite Beach Police Athletic/Activities League

Membership Application

1089 South Patrick Drive Dr. Satellite Beach, FL 329037

(321) 777-TEEN (-8336)

Name: ___________________________________________________________________________

             Last                                        First                                                      Middle

Address: _____________________________  City: _______________________________________

State: ______   Zip Code: __________  Home Phone: _______________________________________

DOB: _______________  Age: ___________ Race: _____________ Gender: ____________________

School : ____________________________________________________ Grade: ________________

Parent/Guardian Name: ______________________________________________________________

Work Phone Number: _____________________  Cell Phone Number: ___________________________

Emergency Contact Person other than Parent/Guardian:

Name: _____________________________________ Phone Number:_________________________

MEDICAL RELEASE AUTHORIZATION AND CONSENT FOR TREATMENT OF CHILD

As parent or legal guardian of ______________________________, I hereby authorize and give my consent for any medical emergency treatment or dental treatment for my son/daughter or child I am guardian of (listed above) should it be deemed necessary by a qualified medical doctor or dentist.  In the event I can not be contacted, I give the authorized PAL coach and/or activity/event supervisor the authorization to act on my behalf should a medical or dental emergency arises while participating in a Satellite Beach PAL activity or event.

LIABILITY WAIVER

In consideration of our accepting this entry, I/We the undersigned, intent to be legally bound, hereby for myself, my heirs, executors and administrators waive and release any and all claims for injury and damages  I/We may have against the Satellite Beach Police Athletic/Activities League, the City of Satellite Beach, the Satellite Beach police Department or our authorized agents and employees for all injuries or damages suffered by said participant while participating in a Satellite Beach PAL sanctioned activity or event.  I/We have insurance protection covering any injuries that may occur while participating in a Satellite Beach PAL sanctioned activity or event.  I/We certify that the information contained herein is true to the best of my/our knowledge.

Participant Name: __________________________________________________________________

Participant Signature: _______________________________________ Date: ___________________

Parent/Guardian Name: ______________________________________________________________

Parent/Guardian Signature: ___________________________________ Date: ___________________

Confidential Optional Information.  This information helps us in our attempts to obtain government funding and/or grants.  Is your child on a reduced or free lunch?                Yes               No

Revised 6/20/2008