SAN MATEO POLICE ACTIVITIES LEAGUE by pte15377

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									                                   SAN MATEO POLICE ACTIVITIES LEAGUE
                                    2000 South Delaware St, San Mateo CA 94403           650-522-7PAL         FAX 650-522-7551



                                                           Membership Application
                                                                           (One application per child)

                                 This information will be maintained in strict confidence and is not furnished or sold to anyone else. It is used
                                                                   solely to ensure successful programming.

                                                                                                                                   New
PLEASE USE INK AND PRINT CLEARLY                                                                                                   Renewal

Child’s Information

Child’s First Name(s): _________________________________Child’s Last Name: ____________________________________

Address: ___________________________________________City________________________State __________Zip_________

Child lives with:                Both parents            Mother           Father          Other:

Father/Guardian’s First Name: _______________________________ Last Name: _______________________________
Phone (Home)                            (Work)                         (Cell/Pager)                            E-Mail

Mother/Guardian’s First Name: _______________________________Last Name: ______________________________
Phone (Home)                            (Work)                        (Cell/Pager)                             E-Mail

Emergency Contact (Other Than Parents or Guardian) First Name:_____________ Last Name: ______________
Phone (Home)                            (Work)                        (Cell/Pager)                             E-Mail

Child’s Birthdate: Month____Date____Year                Age:____Sex: Male Female School:                                  Grade:

Names Of Siblings:

Family Demographics

Family Size: Total number of family members living in your household (adults and children including yourself):

Income: Please check the box that best describes your total household annual income before taxes
          Below $10,000                                              $45,750 - 73,199
          $10,001-$19,999                                            $73,200 - 91,499
          $20,000-$27,449                                            $91,500 and above
          $27,450 - 45,749

Ethnicity: Please check only one box that best describes your child’s ethnicity.
            Arabic / Middle Eastern                                   Asian
            Hispanic                                                  Pacific Islander
            Native American                                           Multiple / Mixed Race
            Caucasian                                                 Other:
            African American
Primary language spoken at home:                  English            Other (What language?) _______________________

Parental status: Pick the one option that best describes your family at this time.
  Single head of household         Married                       Separated/Divorced                Widowed                     Other
  Foster Parents         Guardian

Other status (if applicable):          Disabled household              Elderly household (over 62 years)

Mother’s educational level:            High school or less            Some college             College graduate                 Post graduate

Father’s educational level:            High school or less             Some college            College graduate                 Post graduate
                                         SAN MATEO POLICE ACTIVITIES LEAGUE
                                                      2000 South Delaware Street, San Mateo CA 94403 650-522-7PAL
                                                                 FAX 650-522-7551




Miscellaneous

Child’s T-Shirt size: (youth size) M ____ (adult sizes)                 S   M     L XL XXL _____                        PAL Staff Only:
                                                                                                                         Shirt sent
                                                                                                                            (initials)_______
PAL offers case management services for youth and their families.
Would you like to learn more?  Yes      No

How did you hear about us?
    School              Friend                         Recreation Activity Guide                    Advertisement

      Referral (by whom):_____________________

      Other organization:______________________


                                  We appreciate your assistance in the collection of this information.


PAL Membership Information



PAL Membership dues are $20.00 per child a year, which allows members to participate in as many PAL events as they choose.
                 Scholarships are available. Make checks out to “San Mateo PAL.” Please do NOT mail cash.
                                                      PLEASE SEND PAYMENT TO:

                                             SAN MATEO POLICE ACTIVITES LEAGUE
                                            2000 South Delaware Street, San Mateo, CA 94403

                                                 ANY QUESTIONS CALL: (650) 522-7725

To the extent allowed by law, I hereby absolve the City of San Mateo and San Mateo Police Activities League, its employees, agents,
independent contractors, and officers from all liability which may arise as the result of my/our participation in activities I or any member of my
family account attends or registers into; and, in the event that the above named participant is a minor, I and hereby give my permission for his or
her participation as indicated and in so doing absolve the City of San Mateo, its employees, and officers from such liability. I am aware that if I
have registered for a class involving physical activity, I have taken care to enroll at a class level appropriate to my/our physical abilities and/or
medical condition. I release use of my/our photos taken during program participation from all and any claims and demands resulting from their
use in program publicity.




Signature of Parent or Guardian                                                     Date




To be completed by PAL staff only:
Paid by: Check_______ Cash ________ Credit Card ________                                                       Membership Expires _______
                            SAN MATEO POLICE ACTIVITIES LEAGUE
                                          2000 South Delaware Street, San Mateo CA 94403 650-522-7PAL
                                                                FAX 650-522-7551




                                                                                                Name of PAL Applicant
Medical / Insurance Information
Do you have INSURANCE?                             YES             No
Insurance Company                                                  Policy Number
Physician’s Name                                                           Phone #
Preferred Hospital or Clinic
Allergies for drugs or foods:
Important medical information, special medications, or special instructions we should be aware of:



List any restrictions to medical treatment:




    ******************************************************
     MEDICAL RELEASE: AUTHORIZATION CONSENTING TO TREATMENT OF MINOR

I/We, the undersigned, parent(s) or legal guardians of                                       , a minor, do hereby
authorize the staff of the San Mateo Police Activities League, or an authorized representative, as agent(s) for the
undersigned, to consent to any X-Ray examination, anesthetic, medical or surgical diagnosis, treatment and hospital
care which is rendered under the general or specific supervision of any physician and surgeon licensed under the
provisions of the California Medicine Practice Act on the medical staff of a licensed hospital, whether such
examination, diagnosis, or treatment is rendered at the office of said physician or at such hospital.
It is understood that this authorization is given in advance of any specific examination, diagnosis, treatment, or hospital
care being required, and is given to provide authority and power on the part of our above named agent(s) to give
specific consent to any and all such examinations, diagnosis, treatment, or hospital care which the aforementioned
physician in the exercise of his best judgement may seem advisable.

Father                                                                               Date
or
Mother                                                                               Date
or
Guardian                                                                             Date



 Please note: The San Mateo Police Activities League is also actively involved in the California
 Police Activities League. There will be occasions when our members will be included in CAL
 PAL activities. For this purpose the above medical information is also necessary for the
To be completed by PAL staff only:
 California Police Activities League. A separate Participant Waiver is enclosed.
Paid by: Check_______ Cash ________ Credit Card ________                    Membership Expires _______
               San Mateo Polliice Actiiviitiies League Polliiciies and Procedures
               San Mateo Po ce Act v t es League Po c es and Procedures

         The San Mateo Police Activities League is proud to offer our members quality recreational, educational, and
athletic programming. To better serve our membership, PAL has established some basic policies and procedures that
should answer most questions while creating a fair framework for all of our members and volunteers. Please read the
following information and feel free to contact our staff if you have any questions.

    Registrations:
        Membership applications can be downloaded from the internet at http://www.sanmateopal.org and either
    brought to the PAL Office (San Mateo Police Department) or mailed with membership dues. PAL memberships
    are $20.00 per member for one year starting from the date of application.

        Program registrations are accepted at the PAL office only. You can register for a program by filling out a
    registration form and either turning it in to a PAL staff member at the office, by mail, or by dropping it into the
    mail slot at the PAL office. We accept faxed registrations; however, can make no guarantees that we will
    receive it on time due to potential technical issues.

        Office hours: Monday through Friday 1PM – 5PM. The PAL office may be closed on occasion due to
    programming and staffing needs. Please use the mail box drop located in the police department lobby to the left of
    the counter.

    Please be sure to READ the program fliers completely. They should contain age limits, dates & times of the
    events, a course number, and a registration Start Date and End Date. We will accept registrations within that
    time frame. Staff will fill the classes shortly after the registration End Date and send out confirmations of either
    being in the class or being placed on a wait list.

    Programs:

        Cancellations: We have experienced a large number of cancellations and no-shows for our trips and
    programs. This makes it impossible for staff to take someone from the wait list last minute. All cancellations
    must be given 48 HOURS in advance. No-shows and cancellations less than 48 hours in advance will be assessed
    a $10.00 fee. You will not be allowed to sign up for additional activities until the fee is paid.

         Pick-Ups: We request that you pick up your child from scheduled activities in a timely manner. If an activity
    is scheduled to end at a given time, we recommend you arriving 5-10 minutes early for pick-up. It is unfair for
    volunteers to have to wait for late pick-ups. A $10.00 late fee will be charged every 15 minutes after the
    scheduled pick-up time.

      NOTE: Some trips make it impossible to have an exact pick-up time. In these cases, staff will make every
    effort to call parents/pick-ups either by cell phone or from the office. PLEASE provide staff with telephone
    numbers and contact information that work. We often spend too much time calling parents with their given
    numbers and nobody answers. In this case, late charges may be assessed.

                       The San Mateo PAL staff would like to thank you for your adherence to these policies.

I have read and understand the
San Mateo Police Activities League
Policies and Procedures                     X_______________________________        _______________________________
                                                           Signature                             Print Name


To be completed by PAL staff only:
Paid by: Check_______ Cash ________ Credit Card ________                                   Membership Expires _______
                         CALIFORNIA POLICE ACTIVITIES LEAGUE
                                                  Participant Waiver

NAME:        ______________________________________________________________________
                 Last                    First                   Middle

ADDRESS:           ___________________________________________________________________________
                   Number            Street                  City              Zip

PHONE: _(_____)_______________________                     AGE: _______   Date of Birth: _______________


Allergies to drugs or foods: _____________________________________________________________

Any special medications, important medical info., or special instructions:
____________________________________________________________________________________

List any restrictions to medical treatment: __________________________________________________

Physician/HMO Name:                                        Phone:

Father/Guardian Name:                                      Day Phone:           Evening:

Mother/Guardian Name:                                      Day Phone:           Evening:

EMERGENCY CONTACT PERSON:                                                 PHONE:

EMERGENCY CONTACT PERSON:                                                 PHONE:

   Attach participant
   photo here.
                             Please attach current photo of participant.
                             SEND ONE PHOTO TO CAL PAL AND KEEP THE SECOND FOR
                             EVENT I.D. CARDS



                                     SIGN PAGE 2

                                             (Other Side)
To be completed by PAL staff only:
Paid by: Check_______ Cash ________ Credit Card ________                       Membership Expires _______
                                       VIDEO-PHOTO RELEASE
I understand that during the California Police Activities League program and/or activity, my photograph and/or the photograph of
my child may be taken by the California Police Activities League, producers, sponsors, organizer, and/or assigns. I agree that my
photograph and/or the photograph of my child, including video photography, film photography, or other reproduction of my
likeness or the likeness of my child, may be used without charge by the California Police Activities League, producers, sponsors,
organizers and/or it’s assigns for such purposed as they deem appropriate.



                         AUTHORIZATION TO TREAT A MINOR
I, the parent or legal guardian, of the child listed above, do hereby authorize and consent to any X-ray examination,
anesthetic, medical, or surgical treatment rendered under the general or special supervision of any member of the
medical staff and emergency room staff licensed under the provisions of the Medical Practice Act or a Dentist licensed
under the provisions of the Dental Practice Act and on the staff of any acute general hospital or emergency care facility
holding a current license to operate a hospital or emergency care facility from the State of California Department of
Public Health. I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital
care being required, but is given to provide authority and power to render care which the aforementioned physician, in
the exercise of his/her best judgment, may deem advisable for my child. Further, I understand my child will be
participating in inherently dangerous activities and agree to pay for my child’s medical expenses. I understand that all
effort shall be made to contact me prior to rendering treatment to my child, but any of the above treatment will not be
withheld if I can not be reached. This authorization is given pursuant to the provisions of the California Civil Code.
This consent shall remain in effect until 31 December of the subject year.
RELEASE FROM LIABILITY
In consideration of the acceptance of the application of my child, as a participant in any programs and/or activities of the
California Police Activities League and its member chapters, I and my child hereby agree to assume all risks attendant upon
myself and my child while participating in any California Police Activities League programs and/or activities. I and my child
hereby waive, release, and discharge any and all claims for damages for death, personal injury, or property damage which I or my
child may have, or which may hereafter accrue to me or my child, as a result of my child’s participation in the California Police
Activities League program or activity. I agree to indemnify and hold harmless from liability the California Police Activities
League, its member chapters and/or any of their agents, servants, or employees by reason of any accident, death, injury, or
damages, to persons or property which I or my child may suffer while participating in the California Police Activities League
program and/or activity. This release is intended to discharge in advance the California Police Activities League, its member
chapters and/or any of their agents, servants, or employees by reason of any accident, death, injury or damages to persons or
property which I or my child may suffer, from and against any and all liability arising out of or connected in any way with my or
my child’s participation in the California Police Activities League program and/or activity, even though that liability may arise out
of negligence or carelessness on the part of the persons or entities mentioned above.

It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assigns, and the
heirs and assigns of my child. I agree to assume all responsibility for any property damage or injury to any person caused by me or
my child while participating in the California Police Activities League program and/or activity.

I have read, understand and approve the AUTHORIZATION TO TREAT A MINOR (with any restrictions I may have listed above), RELEASE
FROM LIABILITY and the VIDEO-PHOTO RELEASE.




X
         PRINT NAME OF PARTICIPATING CHILD                                        NAME OF PAL
X
         SIGNATURE OF PARENT OR LEGAL GUARDIAN                                    DATE




To be completed by PAL staff only:
Paid by: Check_______ Cash ________ Credit Card ________                                           Membership Expires _______

								
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