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Household Information

First Name
Last Name
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First Name
Last Name

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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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Emergency Contact
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First Name
Last Name

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
Country
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Child's Information
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First Name
Last Name
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(mm/dd/yyyy)
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Payment
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$
Monthly


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Permissions

In consideration for PCSO PAL permitting my child to participate in this program, I release the Pinellas County Sheriff’s Police Athletic League, and the Pinellas County Sheriff’s Office, deputies, members, employees, activity coordinators, and any volunteer specifically authorized by PCSO to supervise PAL activities from all rights, claims and damages for the negligent actions of any PCSO member arising out of this participation. In signing this document I understand that I am releasing or giving up certain potential legal rights and I further acknowledge that I have been advised that I may wish to seek the advice of legal counsel prior to signing this document. Being so informed, I knowingly and voluntarily execute this release and waiver as evidenced by my signature on the last page of this agreement.

In case of an emergency involving my child, I understand every effort will be made to contact the child’s parent(s) or legal guardian. In the event they cannot be reached, I hereby give my permission to the medical provider selected by the adult leader in charge to secure proper treatment, including hospitalization, anesthesia, surgery, or injections of medication for my child, until such time as I can be contacted.. Also until such time as I can be contacted, I give my permission for medical providers to disclose to the adult in charge the information needed to make an informed decision, including but not limited to disclosing the results of any examination findings, test results, and/or treatment.

I give permission for PAL to transport my child to activities that are off PAL property.

I give permission for PAL to take/use any photograph or video of my child to help publicize our programs, which may include newspaper, brochures, the year-round tabloid, displays and/or any other forms of publicity for the Pinellas Sheriff’s PAL.

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