EASTLAKE POLICE ACTIVITIES LEAGUE _EPAL_

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					              EASTLAKE POLICE ACTIVITIES LEAGUE (EPAL)
                    EPAL Center: 440-EPAL (954-3725)

Eastlake PAL and Junior PAL Mission Statement: The mission of the Eastlake Police
Activities League is to create, foster and sponsor programs designed to promote the physical and
mental well-being of the youth of the City of Eastlake while building social relationships among the
police, youth and other community members.

                                     EPAL Center Rules:

   1. EPAL is open to all Eastlake children ages 10 to 18 years old.

   2. Emergency contacts are very important. No application will be accepted or processed
      without at least three (3) emergency contact names/phone numbers. At least one
      (preferably two) must be from outside the participant’s household.

   3. EPAL ID cards will be issued, as soon as possible, after the application is received.

   4. EPAL participant must sign in and sign out.

   5. Basketball, footballs, scooters and skates must be signed out. Basketball are to be used in
      the gym Footballs are only to used outside.

   6. EPAL participants must register at desk to use a computer Homework assignments get
      priority on the computers.

   7. EPAL participants will obey the instructions of the police officer, monitor or volunteer.

   8. No skateboarding on the premises. Skateboards can be left at the front desk.

   9. No loitering in the daycare hallway until after 6:30 pm

   10. Food and drinks are not permitted in the computer room.

   11. Foul language or music with graphic lyrics will not be allowed.

   12. Abusive language will not be tolerated.

   13. Abusive video games will not be tolerated or accepted.

   14. No energy drinks will be permitted in the PAL Center.

   15. All rules will be strictly enforced


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                  EASTLAKE POLICE ACTIVITIES LEAGUE (EPAL)
                            Disclosure Information

Dear Parents/Guardians:
   Please review the EPAL Center rules with your child. They are very important
      and will be enforced. Not adhering to the rules can result in all EPAL privileges
      being revoked.

      EPAL does hold special activities for the kids (sports events, field trips,
       sleepovers, lockdowns, etc). These events are very popular and a “Sign Up” will
       be required. A permission form for that activity will be required. Your child will
       not be able to attend without this form being signed and returned prior to the
       event.

      Information about EPAL activities will be left on the answering machine each
       week at the EPAL center phone number 440-954-3725. Also, EPAL operates a
       website at EastlakePAL.org

      The application form will be used to provide each participant with his/her own
       EPAL ID card. This card will show that the participant is in good standing. It also
       shows that the parent/guardian has provided EPAL with the appropriate
       documentation.


Video/Photo Release: I understand that during the Eastlake Police Activities League
(EPAL) program and/or activity that my photo and/or the photo of my child may be taken
by EPAL producers, sponsors, organizers, and/or assignees. I agree that my photo or
video of my child may be used without charge by the EPAL producers, sponsors,
organizers and/or its assignees for such purpose as they deem appropriate.

Insurance Disclaimer: EPAL is not responsible or liable in any way in the event of
harm or injury occurring to the participant. It is agreed that the parent or guardian will
not hold EPAL responsible for the welfare or whereabouts of the participant. If the
Parent or Guardian does file a complaint against EPAL, the Parent or Guardian agrees
to pay for EPAL legal fees.

Parent/Guardian’s signature:                      Participant’s signature:



General
Yes   No
         Participant/Parent/Guardian understand, agree & sign the above Insurance
              Disclaimer & Permission Statement.
         Participant has permission to be used in public relations materials.
         Participant may participate in all EPAL club activities in or adjacent to the club
              building.
Date App Recd             Photo #     Date/Initials of Data Entry            ID #       Date ID card issued


                               Eastlake Police Activities League (EPAL)
                                       Membership Application
            Note: ID cards will be issued faster & more accurately if all fields are complete and legible.
Member Info
First Name:                                Middle Name:                   Last Name:


Nickname:                                  Date of Birth:                 Social Security Number:


Gender:                                    Ethnicity:                     Email:
male female
Address:                                   City/State/Zip:                Primary phone #:
                                                                           Cell  Home

                                                                          Secondary phone #:
                                                                           Cell  Home
Current School:                            Grade Level:                   Teacher:




Photo ID Info
Eye color:              Hair color:           Skin color:                Height:               Weight:


Medical Info
Doctor Name                                                  Doctor Phone:


Does the participant have permission to receive              Does the participant receive Medicaid?
treatment by doctor/hospital in case of an                   Yes No
emergency? Yes No
Does the participant have any serious health                 Does the participant have health and/or accident
problems? Yes No                                         insurance? Yes No

If yes, please explain:                                      If yes, name of Carrier:

                                                             Carrier phone #:

                                                             Policy #:

                                                             Member #:
Is participant taking any medications? Yes No              Date of participant’s last medical exam:
If yes, please indicate type/dosage:
                                                             Date this medical info is being completed:




Optional Info: The following may be used for grant information to obtain additional funding to EPAL.
Religion:                     Birth Certificate Copy    City/State of Birth:            Country of Birth
                              Provided: Yes No
                   Eastlake Police Activities League (EPAL) Contacts Page
A minimum of three (3) contacts are required & may not all be from the same household. Please
complete as much information as possible as it may be necessary in an emergency. Contacts
MUST have a minimum of full name, address, phone #, relationship, and must have the final box
with their authority in regards to the participant marked.
PRIMARY Contact
First Name:                    Last Name                   Does participant reside with contact:
                                                            Yes  No
Relationship to participant:   Date of Birth:              Social Security Number:

Address:                       City/State/Zip:             Primary phone #:

                                                            Cell  Home  Work
Occupation:                    Employer:                   Secondary contact #:

                                                            Cell  Home  Work
Employer Address:              Employer City/State/Zip:    Third contact #:

                                                                Cell  Home  Work
Email:
Check all that apply:  Parent/Guardian  Authorized to Pickup Member  Emergency

Contact #2
First Name:                    Last Name                   Does participant reside with contact:
                                                            Yes  No
Relationship to participant:   Date of Birth:              Social Security Number:

Address:                       City/State/Zip:             Primary phone #:

                                                            Cell  Home  Work
Occupation:                    Employer:                   Secondary contact #:

                                                            Cell  Home  Work
Employer Address:              Employer City/State/Zip:    Third contact #:

                                                                Cell  Home  Work
Email:
Check all that apply:  Parent/Guardian  Authorized to Pickup Member  Emergency

Contact #3
First Name:                    Last Name                   Does participant reside with contact:
                                                            Yes  No

Relationship to participant:   Date of Birth:              Social Security Number:

Address:                       City/State/Zip:             Primary phone #:

                                                            Cell  Home  Work
Occupation:                    Employer:                   Secondary contact #:

                                                            Cell  Home  Work
Employer Address:              Employer City/State/Zip:    Third contact #:

                                                                Cell  Home  Work
Email:
Check all that apply:  Parent/Guardian  Authorized to Pickup Member  Emergency
Contact #4
First Name:                    Last Name                   Does participant reside with contact:
                                                            Yes  No
Relationship to participant:   Date of Birth:              Social Security Number:

Address:                       City/State/Zip:             Primary phone #:

                                                            Cell  Home  Work
Occupation:                    Employer:                   Secondary contact #:

                                                            Cell  Home  Work
Employer Address:              Employer City/State/Zip:    Third contact #:

                                                                Cell  Home  Work
Email:
Check all that apply:  Parent/Guardian  Authorized to Pickup Member  Emergency

Contact #5
First Name:                    Last Name                   Does participant reside with contact:
                                                            Yes  No

Relationship to participant:   Date of Birth:              Social Security Number:

Address:                       City/State/Zip:             Primary phone #:

                                                            Cell  Home  Work
Occupation:                    Employer:                   Secondary contact #:

                                                            Cell  Home  Work
Employer Address:              Employer City/State/Zip:    Third contact #:

                                                                Cell  Home  Work
Email:
Check all that apply:  Parent/Guardian  Authorized to Pickup Member  Emergency

Contact #6
First Name:                    Last Name                   Does participant reside with contact:
                                                            Yes  No

Relationship to participant:   Date of Birth:              Social Security Number:

Address:                       City/State/Zip:             Primary phone #:

                                                            Cell  Home  Work
Occupation:                    Employer:                   Secondary contact #:

                                                            Cell  Home  Work
Employer Address:              Employer City/State/Zip:    Third contact #:

                                                                Cell  Home  Work
Email:
Check all that apply:  Parent/Guardian  Authorized to Pickup Member  Emergency

				
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