DANBURY PAL MEMBERSHIP FORM

Alternative text

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

ALL FIELDS ARE REQUIRED UNLESS OTHERWISE NOTED

YOU MUST WRITE NONE IF THERE ARE NO CONDITIONS

PARENT/GUARDIAN CONTACT INFORMATION


EMERGENCY CONTACT INFORMATION


MEDICAL INFORMATION



To induce the Danbury Police Athlectic League to accept registration and permit participation by the above named 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 inquiry 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 dependant
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 THAT WILL GIVE YOU THE OPTION OF PAYING ONLINE OR PRINTING OUT A FORM TO MAIL IN