Howell PAL

Requested Starting Date:

School Child Attends:

Please Circle Program Choice:  K-Wrap – Before Care – After Care – Before Camp – After Camp –

K-Wrap- Reg fee – $50

Monday 

Tuesday 

Wednesday

Thursday

Friday 

Before Care  - Reg fee-$40.00

Monday

Tuesday

Wednesday

Thursday

Friday

 After Care -Reg fee -$40.00

Monday

Tuesday

Wednesday

Thursday

Friday

Child’s Name:

Date of Birth:                                                    

Grade:

Child’s Street Address:

City/State/Zip:

Ethnicity:

Child’s Home Phone:

Grade:

   Sex:

Email Address:

PARENT/GUARDIAN INFORMATION

Permission to Photograph      

Yes              No

PLEASE CIRCLE – YES OR NO

Parent/Guardian Name

Relationship

Emergency Contact

Authorized

Pick-Up

Lives with Child

1)

Yes    No

Yes   No

Yes   No

Telephone –     Home#                                        

Cell/#                                         

Work #

2)

Yes    No

Yes   No

Yes   No

Telephone –     Home#                                        

Cell/#                                         

Work #

Parent Employers Name & Address

Parent 1

Parent Employers Name & Address

Parent 2

Contact Name

Relationship to Child

Emergency Contact

Authorized

Pick-Up

3)

Yes    No

Yes   No

Telephone –     Home#                                        Cell/#                                          Work #

4)

Yes    No

Yes   No

Telephone –     Home#                                        Cell/#                                          Work #

5)

Yes    No

Yes   No

Telephone –     Home#                                        Cell/#                                          Work #

STATE ANY PICK-UP RESTRICTIONS (Copies of Restraining/Court Orders MUST be on file at PAL): 

Physician Name:

Phone #

Address:

Insurance Carrier:

Address:

ID #

Policy #

Group #

ALLERGIES:

MEDICATIONS: 

 1)       Please enroll my child for the period beginning as indicated on the front of this application.  I understand my   child will remain in Howell PAL for period reserved for him/her. 

2)       I authorize Howell PAL to utilize pictures of my child in their advertisements.

3)       I state that we are the parent/guardians having legal custody of the above child and attest that the information above is correct.

4)       I authorize the Director or Director’s designee of the above childcare center to obtain emergency treatment for my child.  I further consent to an x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to the minor at a recognized medical facility, under the general or special supervision of a licensed physician or surgeon.

5)       I also recognize and understand that the use of any equipment and/or my child’s participation in any activity sponsored by the Howell Township Police Athletic League will be done at my own risk, knowing that the use of said equipment and/or participation in said activities may subject my child to physical injury serious or otherwise.  As such, I will not hold the Howell PAL, it’s members, coaching staff/volunteers and directors responsible for any accident or injury that may befall me in the use of said equipment and/or the participation in said activities.  Furthermore, I will provide the Howell PAL with a medical certification form from my child’s doctor attesting to my   child’s physical ability to participate in certain activities requiring notification.

6)       By affixing my signature below, I agree and fully comprehend that I am responsible for all payments incurred with regard to this program. 

Signature of Parent/Guardian

Date