POLICE ATHLETIC LEAGUE of WEST PALM BEACH
2016 Wrestling Academy Registration
$75 Fee
Student Name: ________________________________________________ Nickname: _________________________
Last 4 digits of SSN: ________ DOB: ______/______/______
Age: _______ Male or Female
T-shirt Size:____
School: _____________________________________ Grade: _________ Teacher:___________________________
Parent/Guardian Name: _______________________________________________ Cell Phone ______/_____/_______
Parent/Guardian Address: __________________________________ City______________________ Zip_____________
Parent/Guardian Name: _______________________________________________ Cell Phone ______/_____/_______
Parent/Guardian Address: __________________________________ City______________________ Zip_____________
EMERGENCY CONTACT INFORMATION (other than parents)
Contact person #1
Contact Person #2
Name: _____________________________________
Name:_________________________________________
Relationship: ________________________
Relationship: __________________________
Home Phone: ________________________
Home Phone: _________________________
Cell Phone: ________________________
Cell Phone: _________________________
Child Release Authorization
In the event that I am unable to pick up my child in person, he/she may be released to the following individuals. I
understand that these individuals may be required to present a picture ID in order to pick up my child:
Name: ________________________________ Relationship: _______________________
Name: ________________________________ Relationship: _______________________
Amount Paid $______
Official Use Only:
T-shirt _______ Application reviewed by: _________________________
POLICE ATHLETIC LEAGUE of WEST PALM BEACH
Health History Form
Student Name ______________________________________________
Age________
Height___________
Date _____/______/________
Weight____________
Male or Female
Pleases List All Allergies:
Has student had/or subject to:
______________________________
Epilepsy
Yes No
______________________________
Heart trouble
Yes No
______________________________
Convulsions
Yes No
______________________________
Fainting
Yes No
______________________________
Asthma/Wheezing
Yes No
______________________________
Frequent stomach aches
Yes No
Any other limitations/restrictions:
Diabetes
Yes No
______________________________
Hearing problems
Yes No
______________________________
Ear infections
Yes No
______________________________
Rheumatic Fever
Yes No
______________________________
Does your child know how to swim?
Yes No
Dose the child wear eyeglasses?
Yes No
Any serious illness/operations:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Signature ____________________________________________________
Parent/Guardian
Date _____/______/________
Police Athletic League of West Palm Beach Policy and Liability Waiver
I hereby declare that I am the parent/ guardian of __________________________ and give my consent for his/her
participation in the West Palm Beach Police Athletic League (PAL). In consideration of my child being permitted to
participate, I hereby release, waive, indemnify and hold harmless the City of West Palm Beach, their agents, employees or
volunteers, the State of Florida, the National Police Athletic League, it’s agents or staff or sponsors from any and all
liability for all injury, loss, damage and/or claim of damages to the person or property of my child during his/her
participation with the Police Athletic League, Inc. I hereby grant permission for the West Palm Beach Police Athletic
League and or its agents to photograph and or video tape the above named registrant during his/her/our participation in
activities or use of recreational facilities. I further authorize the use of such photos and/or videos for any promotional
and/or documentary purposes without compensation.
Signature ____________________________________________________
Parent/Guardian
Date _____/______/________
Authorization for Medical Treatment
In the event the Police Athletic League of West Palm Beach, Inc. is unable to reach me when my child has been injured or
needs emergency medical treatment. I authorize the Police Athletic League of West Palm Beach to obtain medical or
hospital care on an emergency basis. I understand that I will be financially responsible for such care.
Signature ____________________________________________________
Parent/Guardian
Date _____/______/________
Authorization for Insurance
In the event of an injury or illness that requires medical treatment, your child’s medical expenses will be covered by your
primary insurance carrier.
Name of insurance company_________________________________________________
Policy and/or Group Number________________________________________________
Signature ____________________________________________________
Parent/Guardian
Date _____/______/________
Transportation Waiver Form
I hereby give permission for my child named above to travel to and from any / all destinations associated with the Police
Athletic League program for the current school year. I understand that the driver of West Palm Beach Police Athletic
League, Inc. is not responsible for any injury/damages which may be incurred on any trip, and in consideration for
providing transportation, I agree to hold the Police Athletic League of West Palm Beach, Inc., the City of West Palm
Beach, and the drivers and owners of the vehicles transporting my child, harmless from claims for injury or damages
occurring during any trip.
Signature ____________________________________________________
Parent/Guardian
Date _____/______/________