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AT RISK: YES NO <br />HAWAII POLICE DEPARTMENT <br />HAWAI'l ISLE POLICE ACTIVITIES LEAGUE <br />PLEASE PRINT AND COMPLETE ALL INFORMATION I TEAM NAME AGE DIVISION I <br />PERSONAL INFORMATION <br />NAME OF PARTICIPANT (Last, First, Middle Initial) <br />N. HILO <br />❑ <br />AGE <br />BIRTH DATE <br />RES. PHONE <br />MAILING ADDRESS <br />S. KONA <br />❑ <br />CITY <br />STATE <br />ZIP CODE <br />SCHOOL <br />KEAUKAHA <br />❑ <br />HAMAKUA <br />❑ <br />GRADE <br />FATHER'S NAME <br />PUNA <br />❑ <br />RES. PHONE <br />BUS. PHONE <br />CELL <br />MAILING ADDRESS <br />HAKALAU <br />❑ <br />CITY <br />STATE <br />ZIP CODE <br />MOTHER'S NAME <br />RES. PHONE <br />BUS. PHONE <br />CELL <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP CODE <br />LEGAL GUARDIAN'S NAME <br />RES. PHONE <br />BUS. PHONE <br />CELL <br />MAILING ADDRESS <br />CITY <br />STATE <br />ZIP CODE <br />ARE YOU CURRENTLY RECEIVING GOVERNMENT SUBSIDY? <br />EXAMPLE: DSS, SOCIAL SECURITY, SSI <br />❑ YES <br />❑ NO <br />ARE YOU CURRENTLY RESIDING IN GOVERNMENT HOUSING? <br />❑ YES <br />❑ NO <br />ARE YOU A SINGLE PARENT FAMILY? <br />[]YES <br />❑ NO <br />FOSTER CARE? <br />❑ YES ❑ NO <br />COURT REFERAL? <br />❑ YES ❑ NO <br />GEOGRAPHICAL LOCATION <br />❑ <br />N. HILO <br />❑ <br />S. KOHALA <br />❑ <br />KA'U <br />❑ <br />S. KONA <br />❑ <br />PAPAIKOU <br />❑ <br />HONOMU <br />❑ <br />KEAUKAHA <br />❑ <br />HAMAKUA <br />❑ <br />N.KOHALA <br />❑ <br />PUNA <br />❑ <br />WAINAKU <br />❑ <br />PEPEEKEO <br />❑ <br />HAKALAU <br />❑ <br />PANA'EWA <br />MEDICAL INFORMATION <br />I give my consent for your Agency to refer my child, if injured or ill, to my family physician when I cannot be reached. Where there is no <br />family Physician available, the discretion for the selection of a doctor will be left to the agency. <br />IN CASE OF EMERGENCY, CONTACT <br />RES. PHONE <br />BUS. PHONE <br />I CELL <br />PHYSICIAN'S NAME <br />OFFICE PHONE NUMBER <br />MEDICAL INSURANCE COVERAGE: <br />POLICY NUMBER <br />EXPIRATION DATE <br />HPDIHIPAL -001A REVISED 3 -11 -09 RETENTION 3 YEARS <br />