Travel Basketball 10-30-17

DANBURY PAL BASKETBALL REGISTRATION FORM

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

THIS FORM IS TO REGISTER FOR THE TRAVEL BASKETBALL PROGRAM

TRAVEL BASKETBALL $250.00

ALL FIELDS ARE REQUIRED UNLESS OTHERWISE NOTED

PARTICIPANTS NAME

DATE OF BIRTH

ADDRESS

CITY, ZIP

SCHOOL

GRADE

AGE

LIST ANY MEDICAL CONDITION(S) THE CHILD HAS

PARENT/GUARDIAN CONTACT INFORMATION

NAME

E-MAIL

HOME PHONE NUMBER

CELL PHONE NUMBER

WORK PHONE NUMBER

EMERGENCY CONTACT INFORMATION

EMERGENCY CONTACT NAME

EMERGENCY CONTACT PHONE

RELATIONSHIP TO PARTICIPANT

Ethnicity Option (for demographic and database purposes) Please specify your ethnicity.

YOUR ETHNICITY IF DIFFERENT THAN ABOVE CHOICES

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 purpose of promoting programs on fliers, social media, and other ways PAL sees fit.

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

PRINT YOUR NAME (PARENT/GUARDIAN)

DATE SIGNED

AFTER SUBMITTING THIS FORM, YOU WILL BE RE-DIRECTED TO A PAYMENT PAGE THAT WILL GIVE YOU THE OPTION OF PAYING ONLINE OR PRINTING OUT A FORM TO MAIL IN