DANBURY PAL FIELD HOCKEY FALL 2017 REGISTRATION

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

THIS FORM IS TO REGISTER FOR THE FIELD HOCKEY

ALL FIELDS ARE REQUIRED UNLESS OTHERWISE NOTED


PARENT/GUARDIAN CONTACT INFORMATION


EMERGENCY CONTACT INFORMATION


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

Payment can be made through PayPal using any type credit card/
Fees Due at time of registration: (please make checks payable to Danbury PAL Field Hockey if not paying online)
Grade 5 – 8: Danbury Resident -$ 125.00 + Jersey Fee $20.00 (optional fee for shorts $15)
Grade 3 & 4: Danbury Resident -$ 50.00 + Jersey Fee $20.00 (optional fee for shorts $15)

Return forms (if not paying online) to: Danbury PAL Field Hockey, 35 Hayestown Rd, Danbury, CT 06811
Click Here to obtain a registration form.

ONLY CHECK THE SHORTS SIZE BELOW IF YOU ARE ORDERING AND PAYING FOR OPTIONAL SHORTS