WESTPORT P.A.L.

Registration & Emergency Form

PLEASE PRINT

NAME OF PARTICIPANT ____________________________________________________ BIRTHDATE __________________________________

ADDRESS _____________________________________________________________________ HOME PHONE ________________________________

HOME E-MAIL ADDRESSES __________________________________________________________________________________________________

ANY ALLERGIES _______________________________________________________________________________________________________________

SPECIAL NEEDS/ACCOMODATIONS ________________________________________________________________________________________

GRADE ___________ AGE _________ MALE________ FEMALE ________    SCHOOL ________________________________________________

NAMES OF PARENTS/GUARDIANS ___________________________________________________________________________________________

MOTHER CELL PHONE ________________________________ FATHER CELL PHONE ___________________________________________

FAMILY PHYSICIAN ___________________________________________________________________________________________________________

PHYSICIAN PHONE _______________________________________ DATE OF LAST TETANUS BOOSTER __________________________

EMERGENCY CONTACT ____________________________________________ PHONE _________________________________________________

(other then parent/guardian)

Participation in competitive athletics may result in severe injury, including paralysis or death.  Improvement in equipment, medical treatment and physical conditioning, as well as rule changes, have reduced these risks, but it is impossible to totally eliminate such occurrences from athletics.  I hereby give my consent to the above named participant to represent Westport P.A.L. in their travel program for local and out-of-town activities.  I hereby authorize Westport P.A.L. to obtain, through a physician of their choice, any emergency care that may become reasonably necessary for the player in the course of any athletic event.  I will not hold the Westport P.A.L., the Town of Westport, and or their employees, agents or volunteers responsible in case of accident or injury as a result of this participation.

_________________________________________________________________________________              ___________________________________

SIGNATURE OF PARENT/GUARDIAN OR ADULT PARTICIPANT                          DATE

EMAIL : ___________________________________________________________________________________________________________________________________________

Other contact numbers:   home:__________________________________work:____________________________________other_____________________________________