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Manchester Police Activities
League Registration Form
| Name __________________________________ |
Date of Birth __________ |
Grade _______ |
| Address ________________________________ |
School ___________________________ |
| Parent / Guardian _____________________ |
(W) Phone _________ |
(H) Phone __________ |
| Insurance and ID # _________________________________________________________ |
I, the undersigned, waive and hold harmless
the Manchester Police Activities League (PAL), its employees, volunteers
and agents from any personal or property damage I or my child may
incur while using PAL facilities or participating in PAL activities
or events. In case of emergency, I give permission to hospitalize
and/or secure necessary treatment, order injections, anesthesia,
or surgery for my child named on this form.
| Signature of Parent / Guardian________________________________ |
Date___/____/_____ |
| Program or activity: |
[ ] tutoring
|
[ ] boxing |
[ ] karate |
[ ] archery |
| [ ] other _____________________________________________________________________________ |
| I give Manchester PAL permission to publish my
child's name and/or photo. |
[ ] yes |
[ ] no |
|
|
The following information is useful in obtaining grants that support
our programs. This survey is voluntary and will be kept confidential.
Please check the appropriate box for your child.
| Race: |
[ ] White |
[ ] Black |
[ ] Hispanic |
[ ] Asian or Pacific Islander |
| |
[ ] American Indian or Alaskan Native |
[ ] Other |
|
| Gender: |
[ ] Male |
[ ] Female |
|
| Disability: |
[ ] No |
[ ] Yes |
Please explain _____________________________________ |
| Number of people in your household: |
[ ] 2 |
[ ] 3 |
[ ] 4 |
[ ] 5 |
[ ] 6 |
[ ] 7 or more |
| Combined household income (reported on IRS form 1040): |
|
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Manchester Police Activities League
Membership Card
This pass entitles
_____________________________
(signature)
To all the benefits to be derived
from the Manchester Police Activities League (PAL). This pass may
be revoked for failure to abide by the PAL disciplinary code.
This membership is good for a period
of one year from date of purchase.
Date ____/____/____
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Manchester Police Activities League
Disciplinary Code
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Disrespectful Behavior will
not be tolerated.
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No drugs, alcohol, or illegal
substances of any kind.
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Poor sportsmanship is unacceptable.
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Criminal activity may be grounds
for removal from any PAL program.
Police Activities League Member
Signature
__________________________
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Please complete this registration
form and forward it to:
Manchester PAL, Joanne Tedford, Manchester Police Department
P.O. Box 191, 239 East Middle Turnpike, Manchester, CT 06045-0191
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