REGISTRATION FEE  $40 (6 wks)  $25/mo./participant for all in the intermediate class at Carmichael School on approval 

SANTA CLARA POLICE ACTIVITIES LEAGUE    				Paid $____________      Date__________ 
JUDO REGISTRATION FORM for Child or Adult	        				 Check ______Cash 
601 EL CAMINO REAL, SANTA CLARA, CA 95050   			
PHONE: (408) 615-4879   FAX (408) 984-1407					                Shirt Size if applicable: YS     YM     YL  
Office Hours: 1 PM-6 PM  (M-F)							(Circle One)  AS    AM    AL   AXL     
  
CHILD’S or Registrant’s NAME___________________________________________DATE OF BIRTH _______________ AGE ______
Male___ Female___ 
 
ADDRESS_______________________________________________________________________________________________________ 
               STREET                                                       			CITY                                              ZIP CODE 

HOME PHONE__________________________________________________________________________________________________

SCHOOL CURRENTLY ATTENDING if applicable_____________________________________________________________________ 
 
PARENTS/GUARDIANS______________________________________________HOME PHONE NO:____________________________          
 
WORK NAME & ADDRESS________________________________________________________________________________________

WORK PH:_____________________CELL:___________________Email: __________________________________________________ 
 
I understand that no refunds will be issued after I sign up.  I will be responsible for transporting me or my child to all practices and tournaments if applicable.  
 
PARENTAL CONSENT, INSURANCE NOTIFICATION, AND/OR MEDICAL TREATMENT AUTHORIZATION  
 
I, the parent/guardian of the above name candidate for a position on a SANTA CLARA PAL team, hereby give my approval to his/her participation in any and all PAL activities during the current season or session.  I do hereby assume all risks and hazards incidental to such participation including transportation to and from activities.   I do hereby waive, release, absolve, indemnify and agree to hold harmless, the City of Santa Clara, Santa Clara PAL, the respective sanctioning associations organizations or leagues and the organizers, sponsors, supervisors, participants and persons transporting my child or myself to and from activities, for claims arising out of injury to my child or myself.   
 
Santa Clara PAL has group accident insurance coverage for medical and hospital expenses, with a deductible for each accident.  The insurance is secondary when there is any other valid and collectible insurance provided by parent/guardian.  Limited coverage is provided for any one accident with limited dental coverage for sound, natural teeth.  A copy of the policy is available for inspection at the PAL office.  In signing the foregoing release, I acknowledge that: (1) any claim for medical service which arises out of an injury must be reported to a PAL league official within thirty (30) days of the date of injury; (2) I have read the forgoing release, understand it and signed it voluntarily.  I further understand that any registration fee or other sums paid does not constitute a direct premium payment for insurance. 
 
Do you have HEALTH/GROUP Medical Insurance:   YES (  )    NO (   ) 
CARRIER:__________________________________  PLAN #____________________ or MEDI-CAL #_______________________________________ 
 
In the event of injury to my child or for myself, ______________________________, I hereby grant authority to a qualified physician to render such medical treatment as said physician deems necessary under the circumstances.  I/we, the Parents/Guardian of the above names SANTA CLARA PAL Candidate have read and understand the above Parental Consent, Insurance Information Clause, and Medical Treatment Authorization.  By signing this registration Form, I grant permission for my child or myself to participate in all officially recognized PAL activities. 

Photographs: Santa Clara PAL reserves the right to photograph facilities, activities, program participants for promotional purposes. Photos may be used in brochures, displays and with press releases or on the City or PAL websites. Individuals may submit their photos for consideration. 

 ____________________________________________________________________________________________________________________________________________
Emergency Contact                                    		Emergency Phone Number                                             		Relationship 
 
PARENTS SIGNATURE:___________________________________________________________________________________________Date________________________ 
    (IF PARTICIPANT IS UNDER 18) 
 
PARTICIPANT’S SIGNATURE_______________________________________________________________________DATE_____________________________rev.1/9/17