NAME            DATE OF BIRTH //

ADDRESS            SCHOOL (SEPT. 2003)

TOWN _ FANWOOD SCOTCHPLAINS                                                        GRADE (SEPT. 01) _ 4 5 6 7 8

TELEPHONE --                                                         WEIGHT

DID APPLICANT PLAY IN 2002? YES     NO     IF YES, WHICH TEAM? A  B  C  D

IF ANY OF THE FOLLOWING QUESTION APPLY, PLEASE PROVIDE DETAILS ON THE BACK OF THIS FORM:

• DOES THE APPLICANT HAVE ANY PHYSICAL OR OTHER IMPAIRMENTS            YES     NO

• DOES THE APPLICANT USE ANY MEDICATION                                                        YES     NO

THE SUCCESS OF OUR PROGRAM DEPENDS ENTIRELY ON VOLUNTEER ASSISTANCE PARENTS - PLEASE INDICATE AREAS IN WHICH YOU CAN HELP:

COACHING   FUND-RAISING   CONCESSION STAND   FIELD MARKERS   P.A. ANNOUNCER

TO BE COMPLETED BY PARENT OR GUARDIAN:

     THE APPLICANT NAMED ABOVE HAS MY PERMISSION TO PARTICIPATE IN THE SCOTCH PLANS P.A.L. FOOTBALL PROGRAM.  IN CASE OF INJURY TO THE ABOVE NAMED APPLICANT, I WILL NOT HOLD THE POLICE ATHLETIC LEAGUE OF SCOTCH PLAINS INC. NOR IT'S OFFICERS, DIRECTORS, COACHES OR OTHER VOLUNTEERS RESPONSIBLE.

NAMES OF PARENTS/GUARDIANS

SIGNATURE OF PARENTS/GUARDIAN ______________________________________________DATE_______________

"COPS FOR KIDS"