Applicant’s Name:

Address:

City:

State:

Zip Code:

Email:

Cell Phone:

Birth Date:

School Attended:

Grade:

Ethnicity:
White/CaucasianAfrican AmericanHispanicAsian

Free or Reduced Lunch Program:
This helps us when applying for grant funding to support and enhance the PAL Program.
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I, being the parent or legal guardian of the applicant above, do hereby approve of his/her participation in all activities the Millville Police Athletic League and to hereby release the City of Millville, the Millville PAL Organization including it’s Board & Officers, the Millville Police Department, the Millville Board of Education and it’s members and any officials and/or coaches being employees of the organization, whether paid and/or volunteer, from all liability from persona injury and/or property damage resulting from his/her participation in any of the PAL activities in which he/she may take part.

The PAL Organization reserves the right to cancel and/or suspend any membership of those individuals not complying with its
rules and regulations.

I understand that the above information is being requested in to allow Millville PAL and its partners to seek funding opportunities to help offset expenses incurred through the facilitation of activities and events. I understand at no time will my child’s name be disclosed. Random numbers will be used for identification purposes. I give my consent for PAL Board members to access and report my child’s school grades and discipline incidents if needed for these stated reporting purposes. This information will be used for reporting purposes of the Police Athletic League of New Jersey and local chapter.

Signature (Parent/Guardian) *
I have read the above and understand and agree to comply with all PAL policies.

Date *

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