Richmond Police Activities League Youth Membership Application

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Richmond Police Activities League Youth Membership Application

2200 Macdonald Avenue, Richmond, CA 94801 | Phone: (510) 621-1221

If membership is accepted, the membership fee is $30 per calendar year per youth. The fee is not prorated for a partial year. Membership acceptance is determined following completion of the Richmond PAL orientation and assessment. You will be notified if your application has been accepted. No fee is due until notification of acceptance is determined. Please submit one form for each youth.

No Refunds. No Personal Checks. Cash, Money Order, Visa/MasterCard are the only accepted forms of payment. Membership is valid from the date of membership acceptance through the calendar year-end date of December 31. Some programs may have additional fees. A copy of the youth's birth certificate must be on file at Richmond PAL.

PLEASE NOTE: All application questions with an asterisk (*) require an entry or the application will not progress and cannot be submitted online. If you have no entry for a required field, you may enter 'N/A'.

Youth's First Name *

Youth's Last Name *

Youth's Birthdate *

YYYY

Youth's Gender *

Female

Male

Prefer not to say

Other:

Youth's Address (include City, State, and Zip Code) *

Youth's Home Phone Number *

Youth's Mobile Phone Number

Youth's Email Address

Youth's Ethnicity *

American Indian/Alaska Native

Asian: Chinese

Asian: Japanese

Asian: Filipino

Asian: Korean

Asian: Vietnamese

Asian: Asian Indian

Asian: Laotian

Asian: Cambodian

Asian: Other

Black or African American

Hispanic, Latino, or Spanish

Middle Eastern/North African

Native Hawaiian/Pacific Islander: Native Hawaiian

Native Hawaiian/Pacific Islander: Guamanian

Native Hawaiian/Pacific Islander: Samoan

Native Hawaiian/Pacific Islander: Other

White

Other identified ethnic origin, ethnicity, or race

Decline to state

Multi-ethnic origin, ethnicity or race

Name of School youth is attending currently *

Grade/Level in School *

Any Medical Condition and/or Medication Needed (Please list) *

Total Number in Household *

Household Annual Income: *

$10,000 to $20,000

$20,001 to $30,000

$30,001 to $40,000

$40,001 to $50,000

$50,001 and up

Other:

Household Type *

Group Home/Foster Care

Unhoused/Unstable Housing (shelter, couch surfing, living in vehicle, etc.)

Parent(s)

Family Member (Grandparents, Aunt or Uncle, Sibling or Cousins)

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