34TH Annual HI-PAL Winter Basketball Classic (Packet)

Home

HAWAII POLICE DEPARTMENT AT RISK: YES NO HAWAII ISLE POLICE ACTIVITIES LEAGUE PLEASE PRINT AND COMPLETE ALL INFORMATION TEAM NAME AGE DIVISION PERSONAL INFORMATION NAME OF PARTICIPANT (Last, First, Middle Initial) AGE BIRTHDATE RES PHONE MAILING ADDRESS CITY STATE ZIP CODE SCHOOL GRADE FATHER'S NAME RES PHONE BUS PHONE CELL MAILING ADDRESS CITY STATE ZIP CODE MOTHER'S NAME RES PHONE BUS PHONE CELL MAILING ADDRESS CITY STATE ZIP CODE LEGAL GUARDIAN'S NAME RES PHONE BUS PHONE CELL MAILING ADDRESS CITY STATE ZIP CODE ARE YOU CURRENTLY RECEIVING GOVERNMENT SUBSIDY? ❑ YES ❑ NO ARE YOU CURRENTLY RESIDING IN GOVERNMENT HOUSING? ❑ YES ❑ NO ARE YOU A SINGLE PARENT FAMILY? ❑ YES ❑ NO FOSTER CARE? ❑ YES ❑ NO COURT REFERRAL? ❑ YES ❑ NO ❑ N. HILO ❑ S. KOHALA ❑ KA'U ❑ S. KONA I ❑ PAPAIKOU l ❑ HONOMU I ❑ KEAUKAHA ❑ HAMAKUA ❑ N. KOHALA ❑ PUNA ❑ WAINAKU I ❑ PEPEEKEO I ❑ HAKALAU I ❑ PANAEWA PHYSICAL DISABILITY, IF ANY; I give 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 family physician available, the rlisr.ratinn fnr —1— inn of n rinrtnr will ha loft to tha nnanr.v IN CASE OF EMERGENCY, CONTACT RES PHONE BUS PHONE CELL PHYSICIAN'S NAME OFFICE PHONE NUMBER MEDICAL INSURANCE COVERAGE POLICY NUMBER EXPIRATION DATE Iriy0yATyyAIIarDIE mr ofyirearhrA PARENT(S) OR LEGAL GUARDIAN: ON BEHALF OF (MINOR), FOR AND CONSIDERATION OF SAID MINOR BEING PERMITTED TO PARTICIPATE IN THE HI -PAL SPONSORED ACTIVITIES, HEREBY EXPRESS;Y AGREE(S) A That there is a substantial value and benefit to be derived by Minor in TYPE OF ACTIVITY FROM -TO (DATE) participating in this activity sponsored by the COUNTY B That they shall forever release and waive all rights to bring suit or claims against and will indemnify and hold harmless, the County of Hawaii, it's officers, agents and employees, HI -PAL program, the Hawai'i Police Department, or any representative, sponsor, manager, coach, trainer, or person who is in any manner connected with the operation of the HI -PAL Program, an account of any and all claims, demands, loss of services, or expenses for property damage, and/or personal injuries, that may arise as a result of said minor's participation in or transportation to and from the subject HI -PAL activity. C That COUNTY is not to be held liable for death or injuries resulting during period when MINOR is transported to ACTIVITY by persons other than employees of the COUNTY. D I To give consent to allow MINOR to actively participate in ACTIVITY. E That PARENT(S) recognizes and understands that participation in ACTIVITY involves risk of death, personal injury, and/or property damage, commonly inherent in such activity F That MINOR, through PARENT, or LEGAL GUARDIAN, voluntarily chooses to participate in ACTIVITY, to which action PARENT or LEGAL GUARDIAN, gives approval and consent. G That said MINOR is in reasonable good physical and mental health, such that MINOR can safely participate in ACTIVITY. H To notify a representative from the HI -PAL Program if there is any change in MINOR's physical and/or mental condition such that MINOR cannot safely participate in ACTIVITY. Dated: 20 Hawai'i Father Mother Legal Guardian H PD/H I PAL -00 1 B REVISED 3-11-09 RETENTION 3 YEARS