REGISTRATION FEE    $35.00 (6 wks)
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) 615-4880   FAX (408) 984-1407					                Shirt Size:      YS     YM     YL  
Office Hours: 1 PM-5 PM  (M-F)		(Circle One)   AS    AM    AL   AXL   AXXL  AXXL              
  
Child or Applicant’s NAME___________________________________________DATE OF BIRTH _______________ AGE ______
Male___ Female___ 
 
ADDRESS_______________________________________________________________________________________________________ 
               STREET                                                       			CITY                                              ZIP CODE 

HOME PHONE____________________________________Email:__________________________________________________________

SCHOOL CURRENTLY ATTENDING if applicable_____________________________________________________________________ 
 
PARENTS/GUARDIANS______________________________________________Cell PHONE NO:______________________________          
 
WORK NAME & ADDRESS________________________________________________________________________________________

WORK PH:____________________________________ 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.  
 
CONSENT, INSURANCE NOTIFICATION, WAIVER & RELEASE OF LIABIITY AND/OR MEDICAL TREATMENT AUTHORIZATION – SIGNATURE REQUIRED (fill out  this section only if registrant is an Adult)
 
I, the above name candidate for a position on a SANTA CLARA PAL team, hereby give my approval in participating 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 to and from activities, for claims arising out of injury. I, the Applicant, state that I am 18 years of age or over. In consideration of being permitted to participate in any way, I acknowledge and agree to release, waive and discharge, to the greatest extent permitted by law, SC PAL from or for all claims, demands and case of actions or any other liabilities which may arise or be caused in whole or in part by the negligence of SC PAL in conjunction with or arising out of membership with SC PAL, and their action or lack thereof of SC PAL and agree that I know and understand the risks involved in the sport of Judo and do hereby assume these risks and accept responsibilities for any damages or injuries engaging in the contact sport of Judo. 

X______________________________________________      ______________________________________________________________________________________
Adult Registrant’s Signature Only			 	 Printed Name				Date

I state that I am the parent/legal guardian of_______________________________(the Applicant), a minor.  I agree to indemnify and hold harmless SC PAL for any expenses incurred, claims made, or liabilities assessed against them as a result of any injury, death, or insufficiency of legal capacity.  I consent to the Applicant’s becoming a participant of SC PAL Judo program and participating in Judo sessions, practices, clinics and events sponsored by SC PAL. 
 ____________________________________________________________________________________________________________________________________________
PARENTAL INDEMNIFICATION

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. I state that I am the parent/legal guardian of______________________________(child’s name), a minor.  I agree to indemnify and hold harmless the SC PAL for any expenses incurred, claims made, or liabilities assessed against them as a result of any injury, death, or insufficiency of legal capacity.  I consent to my child attending SC PAL Judo sessions and participating in classes,  practices, clinics, and events sponsored by SC PAL. 

X______________________________________________________   ______________________________________________________   ______________________
Parent/Legal Guardian Signature (required if Applicant is Under 18)				Printed Name			Date
 
Do you have HEALTH/GROUP Medical Insurance?:   YES (  )    NO (   ) 
CARRIER:__________________________________  PLAN #____________________ or MEDI-CAL or  Medical File#_________________________________________ 
 
In the event of injury, ______________________________, I hereby grant authority to a qualified physician to render such medical treatment as said physician deems necessary under the circumstances.  I, per above name, a SANTA CLARA PAL Candidate have read and understand the above consent, Insurance Information Clause, and Medical Treatment Authorization.  By signing this registration Form, I grant permission 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