P.B.A. 56                           P.B.A. 105

P.O. Box 5081        Phillipsburg NJ  08865

REGISTRATION FORM - PLEASE FILL OUT THIS FORM COMPLETELY

DATE    ACTIVITY

WAS THIS SPORT PLAYED FOR PAL LAST YEAR?  YES NO

IF NO, PREVIOUS ORGANIZATION PLAYED FOR

CHILDS NAME

CHILDS BIRTHDATE

ADDRESS

PARENT/GUARDIAN

EMAIL PHONE

MEDICATION BEING TAKEN

ALLERGIES

ANY PRIOR HEALTH PROBLEMS THAT MAY BE OF IMPORTANCE IN CASE OF AN ACCIDENT OR SERIOUS INJURY

IN CASE OF EMERGENCY, PLEASE CALL:

NAME      RELATIONSHIP               PHONE

NAME      RELATIONSHIP               PHONE

NAME      RELATIONSHIP               PHONE

FAMILY PHYSICIAN

ADDRESS

P.A.L. HAS ADOPTED A POLICY THAT THIS WAIVER MUST BE SIGNED AND DATED FOR EVERY CHILD.  IF THIS FORM IS NOT SIGNED AND DATED BEFORE THE START OF THE FIRST PRACTICE, YOUR CHILD WILL NOT BE PERMITTED TO PARTICIPATE IN ANY ACTIVITIES. 

BY SIGNING THIS FORM I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD THE RULES GOVERNING THE ACTIVITIES OF THE PHILLIPSBURG POLICE ATHLETIC LEAGUE.  I AGREE TO ABIDE BY THE TERMS SET FORTH WITHIN.

REGISTRATION FEE $25.00. MAIL CHECK TO: KEVIN MACK, TREASURER, 942 SIGSBEE AVE, ALPHA NJ 08865

PARENT/GUARDIAN   DATE

CHILD   DATE