Please provide the following contact information:

Registrations are only being accepted for the following sports. Please indicate which sport your child is registering for.

All fields in red must be completed before the form can be successfully submitted.

First Name
Last Name
Date of Birth
Current Age
Estimated Weight	Football Only *Note* Requires official weight measure by Parks and Recreation Staff.  Please be prepared to have your child officially weighed before the season.  A special date and time will be set up for PAL registrants.  Successful football registration cannot be successful without it.  Call 444-7618 with questions.
Street Address
Address (cont.)
City
State
Zip Code
Home Phone
Today's Date
E-mail
School
Grade
Gender	Male   Female
Ethnicity	African American Asian Caucasian Hispanic Pacific Islander Other
Family Income Please know that PAL keeps  this information confidential and uses this information for seeking grant and donor dollars.	$0-$14,999 $15,000-$24,999 $25,000-$34,999 $35,000-$49,999 $50,000+ Decline- Not Recorded
Number in Household
T-Shirt Size	Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large
Do you want to volunteer to coach?	Yes, I want to be the head coach. Yes, I want to be an assistant coach. No, I do not want to coach.
Parent/Guardian  1
Parent/Guardian 1 Phone
Parent/Guardian 1 Work #
Parent/Guardian 1 Cell #
Parent/Guardian 1 Pager #
Parent/Guardian 2
Parent/Guardian 2 Phone
Parent/Guardian 2 Work #
Parent/Guardian 2 Cell #
Parent/Guardian 2 Pager #
Emergency Contact 1
Relationship
Home Phone
Work Phone
Cell Phone
Pager Phone
Emergency Contact 2
Relationship
Home Phone
Work Phone
Cell Phone
Pager Phone
	PAL does NOT provide primary medical insurance  on this youth – you MUST have medical insurance. PAL insurance only covers as a secondary policy.
Insurance Company Name
Insurance Company
Group #
Name Insured
Allergies/Medical Issues
Payment Method- You will be taken to an online payment page upon successful submission of this form.	Online Payment (Check or Credit Card) Check by mail Check in person Cash in person
Comments?

PAL PLEDGE

As a PAL participant, I promise to conduct myself in a respectful manner with all my coaches and other PAL participants.  Further, I pledge to keep all PAL activities drug, alcohol, and smoke free.

  Yes, I affirm.   Parent/Guardian Name

Emergency Notification & Release of Liability

If my child is injured while participating in a PAL activity, every effort will be made to contact me at the phone numbers I have listed above.  If I am unable to be reached, I’ve listed two other people (emergency contacts) who can be contacted. 

I agree to allow PAL to administer any necessary first aid treatment seen appropriate for my child.  As the parent or legal guardian of this child, I hereby authorize and give my consent for any emergency medical, surgical, or dental treatment deemed advisable by a qualified medical doctor or dentist, in the event of a medical or dental emergency that arises while participating at a PAL activity.

As the parent or legal guardian of the participant here listed, I hereby acknowledge and agree to hold harmless and release from civil liability, the Colorado Springs Police Athletic League, the National Police Athletic League, the Colorado Springs Police Department, and the City of Colorado Springs from any medical injury or personal or property damages that may arise while participating in a PAL activity. Through signing below, I agree to all of the above.

  Yes, I affirm.   Parent/Guardian Name

Photo Release

As a parent or legal guardian of the above participant, I give my permission for my child to be photographed or videotaped and allow PAL to release said pictures for publicity purposes.

  Yes, I affirm.  Parent/Guardian Name

By submitting this form, I understand that my child's registration will not be complete until payment is received.  (You will be taken to an online payment instruction page upon successful submission.)