RICHMOND PAL
2200 MACDONALD AVE.
RICHMOND, CA 94801
(510) 621-1221
YEARLY REGISTRATION
COST: $20.00 MEMBERSHIP – NO REFUNDS! NO PERSONAL CHECKS!
CASH, MONEY ORDER, VISA OR MASTERCARD ONLY!
MEMBERSHIP IS VALID FOR ONE YEAR FROM DATE OF REGISTRATION. SOME PROGRAMS MAY
HAVE ADDITIONAL CHARGES. A COPY OF THE CHILD’S BIRTH CERTIFICATE MUST BE ON FILE.
PLEASE PRINT ALL INFORMATION – ONE FORM PER MEMBER
CHILD’S FIRST NAME
CHILD’S LAST NAME
BIRTHDAY
ADDRESS
M/F
CITY
HOME PHONE
ZIP
CELL PHONE
ETHNICITY
PLEASE CHECK ONE
AFRICAN
AMERICAN/BLACK
BLACK/WHITE
CHILD EMAIL ADDRESS
AMERICAN
INDIAN / ALASKAN
AMER.
INDIAN/WHITE
ASIAN
ASIAN/WHITE
WHITE
HISPANIC
PACIFIC ISLANDER/
HAWAIIAN
MULTIOTHER
RACIAL
GRADE
AMER. INDIAN/BLACK
SCHOOL NOW ATTENDING
EXPLAIN ANY MEDICAL CONDITIONS AND ANY MEDICATIONS NEEDED FOR THOSE CONDITIONS
HOUSEHOLD SIZE
PLEASE CHECK ONE
HOUSEHOLD TYPE
PLEASE CHECK ONE
1 2 3 4 5 6 7 8 9 10
GROUP
HOME
FOSTER
CARE
HOUSEHOLD INCOME
SHELTER
EXTREMELY
LOW
GUARDIANSHIP
PARENT
GRANDPARENT
VERY
LOW
LOW
AUNT/UNCLE
MODERATE
SIBLING
HIGH
OTHER
HEAD OF HOUSEHOLD
EMPLOYER & OCCUPATION
WORK PHONE
PAGER/CELL
OTHER PARENT/GUARDIAN
EMPLOYER & OCCUPATION
WORK PHONE
PAGER/CELL
HEAD OF HOUSEHOLD EMAIL
OTHER PARENT EMAIL
EMERGENCY CONTACT NAME/RELATIONSHIP
EMERGENCY CONTACT NAME/RELATIONSHIP
ADDRESS
ADDRESS
CITY/STATE/ZIP
CITY/STAT/ZIP
PHONE
PHONE
“I do hereby release Richmond PAL, it’s agents and employees, from any and all claims of any kind, for loss, damages or injuries while my child is participating in
activities of the Richmond Police Activities League.”
“I also understand that during the Richmond PAL programs and/or activities, my photograph(s) and/or the photograph(s) of my child may be taken by the Richmond
Police Activities League, producers, sponsors, organizers, and/or assigns. I agree that my photograph(s) and/or the photograph(s) of my child, including video
photography, film photography or other reproductions of my likeness and/or the likeness of my child, may be used without charge by the Richmond Police Activities
League, producers, sponsors, organizers and/or it’s assigns for such purpose as they deem appropriate. I have read, understand and approve the Video/Photo Release
above.”
“I swear that all above information is true to the best of my knowledge and I am aware that the information will be verified.”
PARENT/LEGAL GUARDIAN NAME
FOR OFFICE ONLY
DATE PAID __________ FEE _________
APPROVED BY _____________________
PLEASE PRINT PARENT/GUARDIAN NAME
PARENT/LEGAL GUARDIAN SIGNATURE
2200 Macdonald Ave.
Richmond, CA 94801
(510) 621-1221
AUTHORIZATION RELEASE FORM
I, ________________________________ hereby authorize Richmond Police Activities League
Parent/Guardian (Print)
to obtain the necessary school records regarding my child _____________________________
Child’s Name (Print)
for tracking purposes related to grants.
____________________________________________
Parent/Guardian Signature
School
_________________________
Date
PAL BUILDING RULES
Effective as of January 1, 2011
 HOMEWORK help will be given to any student asking for it.
 ALL MEMBERS MUST BE PARTICIPATING IN ONE OF THE SCHEDULED ACTIVITIES BETWEEN 4:00pm –
6:00pm. Members may not move freely between activities.
 ALL FOOD AND DRINKS MUST BE CONSUMED AT THE GYM HALLWAY TABLES. NO GUM OR SUNFLOWER
SEEDS ALLOWED IN PAL.
 YOU MUST WASH YOUR HANDS AFTER EATING OR USING THE BATHROOM
 DO NOT HANG AROUND THE FRONT DOOR AREA OR OUTSIDE
 NO HOODS, HATS OR HEADRAGS ALLOWED TO BE WORN IN THE BUILDING
 NO BAD LANGUAGE, ATTITUDE, OR AGRESSION TOWARD EACH OTHER OR STAFF. You could be suspended
for a week or longer.
 NO RUNNING IN THE BUILDING AND NO WALKING IN THE HALLWAYS EXCEPT TO GO TO THE BATHROOM
 PLEASE FLUSH TOILETS AND URINALS AND PUT ANY PAPER IN THE GARBAGE
 ALL PAL PROPERTY MUST BE TREATED WITH RESPECT. Any member intentionally causing damage will be
responsible for the cost of repair.
 MEMBERS ARE FREE TO LEAVE THE BUILDING AT ANY TIME BUT MUST SIGN OUT AND
SIGN BACK IN WHEN RETURNING
 RICHMOND PAL IS NOT RESPONSIBLE FOR ANY LOST OR STOLEN ARTICLES
I HAVE READ OR HAVE BEEN READ THESE RULES, UNDERSTAND THEM AND I AGREE TO ABIDE BY THEM
Participant’s Signature _______________________________________. Date: _______________________