Westport CT 06880 The Westport Police Athletic League is a leading non profit organization providing youth athletic programs and community events to the town of Westport Ct.Nationally recognized for their volunteerism and trail blazing athletic programs

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WESTPORT P.A.L.

Registration & Emergency Form

 

PLEASE PRINT

 

 

NAME OF PARTICIPANT ____________________________________________________ BIRTHDATE __________________________________

 

ADDRESS _____________________________________________________________________ HOME PHONE ________________________________

 

HOME E-MAIL ADDRESSES __________________________________________________________________________________________________

 

ANY ALLERGIES _______________________________________________________________________________________________________________

 

SPECIAL NEEDS/ACCOMODATIONS ________________________________________________________________________________________

 

 

GRADE ___________ AGE _________ MALE________ FEMALE ________    SCHOOL ________________________________________________

 

NAMES OF PARENTS/GUARDIANS ___________________________________________________________________________________________

 

MOTHER CELL PHONE ________________________________ FATHER CELL PHONE ___________________________________________

 

 

FAMILY PHYSICIAN ___________________________________________________________________________________________________________

 

PHYSICIAN PHONE _______________________________________ DATE OF LAST TETANUS BOOSTER __________________________

 

 

EMERGENCY CONTACT ____________________________________________ PHONE _________________________________________________

(other then parent/guardian)

 

 

 

 

Participation in competitive athletics may result in severe injury, including paralysis or death.  Improvement in equipment, medical treatment and physical conditioning, as well as rule changes, have reduced these risks, but it is impossible to totally eliminate such occurrences from athletics.  I hereby give my consent to the above named participant to represent Westport P.A.L. in their travel program for local and out-of-town activities.  I hereby authorize Westport P.A.L. to obtain, through a physician of their choice, any emergency care that may become reasonably necessary for the player in the course of any athletic event.  I will not hold the Westport P.A.L., the Town of Westport, and or their employees, agents or volunteers responsible in case of accident or injury as a result of this participation.

 

 

 

_________________________________________________________________________________              ___________________________________

SIGNATURE OF PARENT/GUARDIAN OR ADULT PARTICIPANT                          DATE

 

 

 

 

EMAIL : ___________________________________________________________________________________________________________________________________________

 

 

 

Other contact numbers:   home:__________________________________work:____________________________________other_____________________________________