DANBURY PAL DODGEBALL LEAGUE

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35 Hayestown Road
Danbury, CT 06811
203-778-4725
Fax: 203-730-2660

THIS FORM IS TO REGISTER FOR THE DANBURY PAL DODGEBALL LEAGUE

PAL Members: $55.00 Non-Members: $60.00

ALL FIELDS ARE REQUIRED UNLESS OTHERWISE NOTED


PARENT/GUARDIAN CONTACT INFORMATION


EMERGENCY CONTACT INFORMATION

To induce the Danbury Police Activities League Inc. to accept registration and permit participation by the above mentioned minor child, I hereby give my permission and consent, agree to release, indemnify, and hold harmless the Danbury P.A.L, its officers, staff, and representatives from any claims arising from any injury to above named minor. I hereby give my consent for emergency care prescribed by duty licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or well-being of my dependent.

This also gives PAL permission to take photography and/or video of said participant for the purposes of promoting programs on fliers, social media, and other ways PAL sees fit.


MEDICAL INFORMATION (FILL OUT ONLY IF APPLICABLE)

(example: Asthma, bee stings, peanut butter, etc.)
(Epi-pen, inhaler, insulin etc.)

WAIVER:
To induce the Danbury Police Athletic League to accept registration and permit participation by the above named minor child, I hereby give my permission and consent, agree to release, indemnify, and hold harmless the Danbury PAL, its’ officers, staff, and representatives from any claims arising from any injury to the above named minor. I hereby give my consent for emergency care prescribed by the duly licensed Doctor of Medicine or Doctor of Dentistry. This may be given under whatever conditions are necessary to preserve life, limb or well-being of my dependent. I agree to pay all registration fees on timely basis. Any returned checks will result in a $25 fee to be paid by minors guardian.

This also gives PAL permission to take photography and/or video of said participant for the purpose of promoting programs on fliers, marketing material, and social media for PAL related purposes.

By entering your name below constitutes an electronic signature
that is legal as if you actually signed this document with a pen.


AFTER SUBMITTING THIS FORM, YOU WILL BE
RE-DIRECTED TO A PAYMENT PAGE