Millville PAL Application
Millville PAL is an activities based program that services Millville, NJ residents between the ages of 8 -17 years old, with the only exception being Wrestling that starts at 5 years old. You ***MUST BE  A MILLVILLE RESIDENT*** and fit the age requirements in order to be a valid member. This form is to be completed by the parent or guardian of the applicant that is at least 18 years of age. All areas of this form must be completed prior to being submitted. If the form is not completed and submitted the membership will not be valid. There is a membership fee of $20 required to be paid thru PayPal at the completion of this application.   
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Email *
Child's First Name *
Child's Last Name *
Child's Address *
Child's Date of Birth *
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DD
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Child's Current Age *
Gender *
Race *
Ethnicity *

Total family income includes income from all sources (wages, unemployment, social security, public assistance, interest and dividends, worker’s comp, etc.) for all members of your family who are at least 18 years of age. A family is defined as all persons living in the same household who are related by birth, marriage, or adoption. 

 

Below, find your family size by number, then the income level that best describes your family’s current annual income next to the size of your family. Please note below the household size and income bracket that you fall into next to it (i.e. 5 person, 43,401 to 69,400). 

****DO NOT TYPE THE DOLLAR SYMBOL****

 

-1 Person (16,900 or less) (16,901 to 28,150) (28,151 to 45,000) (Above 45,001) 

 

-2 Person (19,300 or less) (19,301 to 32,150) (32,151 to 51,400) (Above 51,401) 

 

-3 Person (23,030 or less) (23,031 to 36,150) (36,151 to 57,850) (Above 57,851) 

 

-4 Person (27,750 or less) (27,751 to 40,150) (40,151 to 64,250) (Above 64,251) 

 

-5 Person (32,470 or less) (32,471 to 43,400) (43,401 to 69,400) (Above 69,401) 

 

-6 Person (37,190 or less) (37,191 to 46,600) (46,601 to 74,550) (Above 74,551) 

 

-7 Person (41,910 or less) (41,911 to 49,800) (49,801 to 79,700) (Above 79,701) 

 

-8 Person (46,630 or less) (46,631 to 53,000) (53,001 to 84,850) (Above 84,851)  

 

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School Applicant Attends *
Grade *
Do you qualify for the Free or Reduced Lunch Program at school? *
I, being the parent or legal guardian of the applicant, do understand that the above information is being requested to allow Millville PAL and its partners to seek funding opportunities to help offset the expenses incurred through the facilitation of activities and events. I understand that at no time will my child's name be disclosed. Random numbers will be used for identification purposes. I give my consent for PAL Board Members to access and report my child's school grades and discipline incidents if needed for these stated reporting purposes. This information will be used for reporting purposes of the Police Athletic League of New Jersey and local chapter. *
Parent or Legal Guardian Name (First and Last Name) *
Parent or Legal Guardian Phone Number *
E-mail Address *
Emergency Contact Name (First and Last Name), Must be different from Parent or Legal Guardian Above *
Emergency Contact Address *
Emergency Contact Phone Number *
Child's Primary Doctor *
Primary Doctor's Phone Number *
Child's Insurance Company Name *
Insurance ID # *
Insurance Group # *
List any known medical conditions or allergies, be specific and describe reactions (If none then type "NONE") *
List any past significant illnesses or surgeries, provide date and any instructions (If none then type "NONE") *
List any medical restrictions (If none then type"NONE") *
List any medication being taken, name and describe (If none then type "NONE") *
List any academic or behavioral issues, name and describe (If none then type "NONE") *
If my child requires emergency medical care and I cannot be reached, I give my consent to PAL to obtain the necessary medical care for my child. I agree to pay all costs associated with the emergency medical care that my child receives. I understand that every effort will be made to contact me before and after medical care is provided. I understand that this consent will be in effect as of the date of my signing this form and will continue if my child is enrolled in the PAL Program. *
I, being the parent or legal guardian of the applicant, do hereby give permission for my child to travel with the PAL Organization on all trips where they may represent the Police Athletic League of Millville. I further do release PAL and its Directors and/or Coaches from any liability that may occur during the transportation either to or from any activity. *
I, being the parent or legal guardian of the applicant, do understand that the PAL Program features special events in a variety of locations. Media representatives, newspaper and television reporters, photographers, and public relations personnel may be present at these special events to record them. These photographs, videos, and interviews will only be used to promote the PAL Program. I give permission for my child to be photographed or recorded during PAL events and activities, and for all such photographs to be displayed by PAL in any medium (books, newsletters, websites, etc.), whether now or hereafter known or developed. *
I, being the parent or legal guardian of the applicant, do hereby approve of the above listed child's participation in the activities of the Millville Police Athletic League and to release the City of Millville, the Millville PAL Organization including its Board and Officers, the Millville Police Department, the Millville Board of Education and its members, and any officials and/or coaches being employees of the organization, whether paid and/or volunteer, from all liability from personal injury and/or property damage resulting from his/her participation in any of the PAL activities in which he/she may take part. 

The PAL Organization does reserve the right to cancel  and/or suspend any membership of those persons not complying with its rule, regulation, or code of conduct. 

I have read this statement, understand, and agree to comply with all PAL policies.
*

The dangers and risk of athletic participation are many.  They include, but are not limited to, serious neck and spinal injuries which could result in permanent disability or even death.  They also include possible injury to all aspects of the muscular-skeletal system, which may impair future abilities to earn a living or to participate in social or recreational activities.  Sports such as football, soccer, basketball, and wrestling, which are contact collision sports, present potential for serious injury.  However, serious injuries and even death have also occurred in non-contact sports such as tennis and cross-country activities.  No matter what sport you decide to participate in, there is always a risk of serious injury.

 

Due to the inherent risks and dangers involved with participation in athletics, it is imperative that you recognize the importance of following the proper procedures that will help to ensure your safety. Those procedures will constantly be emphasized by our coaching staff.  Instructions and warnings will be continually provided regarding playing techniques, proper use of equipment, training methods, team rules and safety in general.  For your own protection, please learn to understand and follow all of the rules and regulations pertaining to your safety.

 

In consideration of the Millville Police Athletic League permitting your child to participate in our athletic program, we require that every parent/guardian and student athlete sign this notice acknowledging that they have been advised of the dangers and risk associated with athletic participation.  You will not be permitted to participate in athletics until this form is signed and returned.

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I, being the parent or legal guardian of the applicant, have read and agree to the above Notice of Risk & Dangers of Athletics Participation. I acknowledge that I have been advised of the risks and dangers associated with athletic participation. *

I, being the parent or legal guardian of the applicant  do state that his/her health is good and is able to fully participate in the activities of the Millville PAL and hereby releases the City of Millville, the Millville Police Department, the Millville PAL Organization, including its Board and Directors, or any representative of these organizations from any liability or responsibility for any injury/injuries that may occur.

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The following Code of Conduct policy is promulgated in accordance with the provisions P.L. 2002, Chapter 74

 

PREAMBLE: Interscholastic and youth sports programs play an important role in promoting the physical, social, and emotional development of children.  It is therefore essential for parents, coaches, representatives, volunteers, and officials to encourage youth athletes to embrace the values of good sportsmanship.  Moreover, adults involved with youth sports events should be models of good sportsmanship and should lead by example by demonstrating fairness, respect, and self-control at all times.

 

A rigid code of conduct must be adhered to, in order, to maintain a proper atmosphere and discipline.  Millville Police Athletic League is a privilege, not a right.  Millville Police Athletic League maintains the right to exclude anyone not conforming to the rules and regulations of the program.  Further, Millville Police Athletic League reserves the right to search persons and property, if necessary, to maintain the integrity of the program in relation to controlled substances, alcohol, etc.  Millville Police Athletic League is not bound by the search and seizure rules/laws that police are.

 

As a member of Millville PAL, youth are representing, not only the organization, but also the City of Millville.  This includes conduct in school, at home and in the community.  The standards of acceptable behavior are expected at all times, not just during PAL events.  It is the responsibility of the parent and PAL member to immediately report any school or community violations to the Police Officers on the PAL Board.  A decision of any appropriate action, including restriction, suspension or termination from PAL or PAL events will be made by them.  Failure to report any misconduct may also result disciplinary actions.  I therefore pledge to be responsible for my words and actions while at home, in my community, attending school and/or school activity, or attending, volunteering, coaching, officiating, or participating in any event held or sponsored by Millville Police Athletic League and shall conform my behavior to the following code of conduct:

 

1.     I will not engage in unsportsmanlike conduct with any coach, parent, player, participant, official, or any other attendee.

2.     I will not encourage my child, or any other person, to engage in unsportsmanlike conduct with any coach, parent, player, participant, official or any other attendee.

3.     I will not engage in any behavior which would endanger the health, safety or well-being of any coach, parent, player, participant, official or any other attendee.

4.     I will not encourage my child, or any other person, to engage in any behavior which would endanger the health, safety or well-being of any coach, parent, player, participant, official or any other attendee.

5.     I will not use or distribute drugs or alcohol while at a youth sports event and will not attend, coach, officiate or participate in a youth sports event while under the influence of drugs or alcohol.

6.     I will not permit my child, or encourage any other person, to use or distribute drugs or alcohol at a youth sports event and will not permit my child, or encourage any other person, to attend, coach, officiate or participate in a youth sports event while under the influence of drugs or alcohol.

7.     I will not engage in the use of profanity or vulgar language.

8.     I will not encourage my child, or any other person, to engage in the use of profanity or vulgar language.

9.     I will treat any coach, parent, player, participant, official or any other attendee with respect regardless of race, creed, color, national origin, sex, sexual orientation, or ability.

10.  I will encourage my child to treat any coach, parent, player, participant, official or any other attendee with respect regardless of race, creed, color, national origin, sex, sexual orientation, or ability

11.  I will not engage in verbal or physical threats, bullying, or abuse aimed at any coach, parent, player, participant, official or any other attendee.

12.  I will not engage in improper sexual contact or sexual abuse.

13.  I will not encourage my child, or any other person, to engage in improper sexual contact or sexual abuse.                                     

14.  I will not encourage my child, or any other person, to engage in verbal or physical threats, bullying, or abuse aimed at any coach, parent, player, participant, official or any other attendee.

15.  I will not initiate a fight or scuffle with any coach, parent, player, participant, official or any other attendee.

16.  I will not encourage my child, or any other person, to initiate a fight or scuffle with any coach, parent, player, participant, official or any other attendee.

17.  Proper attire is mandatory.  No revealing clothing will be tolerated.  Shirts must be worn at all times, etc.  Any dress deemed inappropriate by any Millville Police Athletic League representative will be excluded.

18.   I will report any infraction of this code of conduct policy, without holding any related information, immediately to a Millville Police Athletic League representative.

I hereby agree and fully understand that if I fail to conform my conduct to the foregoing, Millville Police Athletic League (PAL) - Code of Conduct policy, while attending, volunteering, coaching, officiating, or participating in/at any Millville Police Athletic League event, I will be subject to disciplinary action, including but not limited to the following in any order or combination:

 

1.     Verbal warning issued by a Millville Police Athletic League representative or an official of a youth sports organization.

2.     Written warning issued by a Millville Police Athletic League representative or an official of a youth sports organization.

3.     Suspension or immediate ejection from any event issued by a Millville Police Athletic League representative or official who is authorized to issue such suspension or ejection by a youth sports organization.

4.     Suspension from multiple events issued by a Millville Police Athletic League representative, or official who is authorized to issue such suspension by a youth sports organization.

5.     Season suspension or multiple season suspensions issued by a Millville Police Athletic League representative, or youth sports organization.

6.     Expulsion from the program by a Millville Police Athletic representative.  An expulsion from the program includes no re-enrollment and no reimbursement of application fee.

7.     Dismissal from any building, field, premises, or parking area of any Millville Police Athletic League event by a Millville Police Athletic League representative or official who is authorized by a youth sports organization.

8.     Any offense(s) that may lead to arrest occurring in the building, on the premises or in any capacity affiliated with the Millville Police Athletic League will result in prosecution if necessary.

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The applicant and I, being the parent or legal guardian of the applicant, have read and agree to be held to the standards written in the Millville Police Athletic League Code of Conduct Policy above. *
By electronically signing  below (typing your first and last name) I am agreeing that the above information is accurate and is being completed by the parent or guardian of the applicant, that is 18 years of age or older. *
Required PAL Membership payment (PayPal) *
A copy of your responses will be emailed to the address you provided.
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