DATE :

PINELLAS COUNTY SHERIFF'S POLICE ATHLETIC LEAGUE Program Registration 10750 Ulmerton Road  Largo, Fl  33778

First Name :

MI :

Last Name :

Address :

City :

Zip :

Home Phone# :

School :

Grade :

Age :

Birth Date :

Sex : MALE FEMALE

Handed : RIGHT LEFT

Parent's Email Address :

T-Shirt Size : YS YM YL AS AM AL AXL AXXL

Race : WHITE BLACK ASIAN HISPANIC OTHER  Other :

MEDICAL INFORMATION :

Doctor's Name :

Doctor's Phone :

In case of Emergency, permission for Doctor/Hospital : YES NO

Does your family have health and/or accident insurance : YES NO

Insurance Carrier :

Policy# :

Group# :

IN CASE OF EMERGENCY :

Parent/Guardian :	Parent/Guardian :
Cell# :	Cell# :
Work# :	Work# :
Home# :	Home# :

Program : MULTI-SPORT OSCEOLA MULTI-SPORT DUNEDIN MULTI-SPORT LEALMAN GOLF CAMP BASKETBALL CAMP BOWLING FOOTBALL CONDITIONING AND SKILLS CAMP - DIXIE HOLLINS HS FOOTBALL CONDITIONING AND SKILLS CAMP - DUNEDIN HS FOOTBALL CONDITIONING AND SKILLS CAMP - SYAA HIGH SCHOO GOLF LEAGUE ICE HOCKEY INTRO TO WRESTLING CAMP SEVEN ON SEVEN PASSING LEAGUE SOCCER SPRING FOOTBALL CLINIC VOLLEYBALL

Transportation Method : NOT APPLICABLE DROP OFF AT CAMP SITE RIDE VAN FROM SAB