Date:

 Program Selection:

Child’s Name: (F/M/L)

            Gender::

Date of  Birth:

        Age:

Home Address:

Parent/Guardian ‘s Name:

 Phone#:

Emergency Contact:

Parent’s Email Address:

School Attending:

Grade:

Have you been in a gang?

If yes what Gang:

I, being the father/mother or legal guardian of   do hereby approve of the participation

of my son/daughter in the activities of the Orange Police Athletic League of Orange, NJ and further do hereby release the employees of the organization whether paid or volunteer, from all liabilities for personal injury or property damages resulting from his/her participation in any of Orange Police Athletic League activities that he/she may take part in.

Orange Police Athletic League reserves the right to cancel or to suspend any membership for not complying with its rules and regulations.

I have read the above and do understand and agree to comply with all Orange Police Athletic League policies.

Family Medical Information: Participant's Emergency Information & Consent Form

Carrier:  

Policy #:        

Group #:

ID#:    

Family Physician Name Address

Phone # Allergies:

Serious Medical Conditions:

I/we hereby grant consent to any and all health care providers designated by Orange Police Athletic League or his/her designee to provide me with any necessary medical care as a result of any injury/illness, if I am unable to decide for myself. This consent includes First Aid and transportation to/from health care providers.

Date: 

Parent/Guardian's Signature___________________________________

Please print this page before pressing submit .

Your child is not registered until you receive a conformation number from our office.

Information listed here is believed to be current at the time of publication. However,

some of the material presented here may have expired since it was posted. Persons

should contact a PAL representative whenever relying on dated material or information

that is subject to change.