Eastlake pal pal youth committee participation form

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Date: _____________



Name: _______________________________ DOB: _____________ Age: ______

Address: ________________________________ City: _________________________
State: _____ Zip: _______ Phone #: _____________ Parent Phone #: _____________
Grade: _______ School: _____________________________________________________

Current PAL Member: ________

New PAL Member: ________
T-Shirt Size: ________

I __________________________________ recognize the danger of Tobacco, Drug and Alcohol use. As a member of the Eastlake PAL Youth Committee and a leader of my peers I understand the importance of setting the example and leading the way in being Tobacco, Drug and Alcohol free.

I PROMISE not to use Tobacco, Drugs or Alcohol or be involved in any activity where Tobacco, Drugs or Alcohol are being used.

________________________________________ ________________________

Signature Date

Members must show up for assigned days.
Proper behavior at School and Home.
Maintain passing school grades.
Presentable dress code:

A. No wild hair colors

B. No face piercings

C. Appropriate Attire

Work front desk at PAL center.
Work Dances (When assigned) -At least once a month
Attend all meetings.
Mandatory PAL Fundraising functions and Events.
Work 10 Hours a Month.
When a member signs up for a work time they must show up for that assigned time unless they have contacted Miss Makenzie.

By signing this I agree to and understand that failure to comply with the above rules could be cause for removal from the PYC Program.

___________________________________________________ ________________________

PYC Member Signature Date

___________________________________________________ ________________________

Parent Signature Date


In consideration of my child ‘s participation in this program, I hereby waive and relinquish any and all claims, demands and/or causes of action whatsoever against the City of Eastlake/Eastlake Police Activities League and I further waive all claims, demands and/or causes of action as above spelled out against a person or persons supervising my child on this event.

My child is years old and has my permission to participate in this program.

(Parent’s Signature)

I understand that during the Eastlake Police Activities League (E-PAL) program and/or activity, my photograph and/or the photograph of my child may be taken by the Eastlake PAL, producers, sponsors, organizer, and/or assigns. I agree that my photograph and/or the photograph of my child including video without charge by the Eastlake PAL, producers, sponsors, organizer, and/or assigns for such purposed, as they deem appropriate.

(Please Print Participant’s Name) (Participant’s Signature)


(Print Parent/Guardian’s Name) (Parent/Guardian’s Signature)

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