DANBURY PAL FIELD HOCKEY WINTER CLINIC REGISTRATION

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

ALL FIELDS ARE REQUIRED UNLESS OTHERWISE NOTED


PARENT/GUARDIAN CONTACT INFORMATION


EMERGENCY CONTACT INFORMATION


MEDICAL INFORMATION

(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. A fee of $25 will be charged for each returned check.

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

Fee of Clinic: $100