San Francisco Police Activities League Chess Program

Personal Information Form

All information must be answered--If the applicant is under 18 the form must be signed/completed by a parent or guardian.

First and Last Name *

Address, City and Zip *

Phone Number *

Does this phone receive text messages? *

Yes

No

Email *

Age *

Date of Birth * +

*

Male

Female

Has your child ever participated in any SFPAL program? If yes, which ones and when? *

How did you hear about our program? *

Ethnicity of Youth *

Household Income Level *

Unemployed

$1-$25,000

$25,000-$50,000

$50,000-$75,000

In Case of Emergency Please Notify

First and Last Name *

Relationship *

Address, City and Zip *

Phone Number *

Preferred Hospital/ Medical Clinic *

Are there any other medical, learning, attention or other concerns that we should be aware of that might in any way impact the participation in the program? If none, please enter N/A. *

Parental Statement

To the best of my knowledge, the information contained herein is accurate and complete. I give my written consent for full participation in the SFPAL Chess Program, subject to limitation(s) noted herein. In the event of an illness or accident in the course of the activity, I request that measures be taken without delay of the judgment of medical personnel dictates.

Parent/ Guardian Signature and Date *

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Parent/ Guardian & Participant Approval

Participants under the age of 18 must have a parent/guardian signature

Participant First and Last Name *

Address, City and Zip *

Date of Birth * +

Age at time of the Participation *

Phone Number for Parent/ Guardian *

Parents/Guardians Must Read the Statement Below Before Approving Application. Participants 18 years or older may sign themselves.

SFPAL Chess Program

The SFPAL Chess Program is a program that requires children to engage in the game of chess activity. The program is a year-round program in partnership with the Novato Chess Club where kids learn the fundamentals of chess.

Agreement

I hereby approve that my child named herein wishes to participate in the above-stated activity.

Waiver of Claims

In consideration of the benefits derived from participation in this activity, any and all claims against the San Francisco Police Department, San Francisco Police Activities League, Novato Chess Club, or against the officers, employees, agents, or other representatives of any of them, or any other persons working under their direction or engage in the conduct of their affairs, arising out of any accident, connection with or incidental to the activity, are hereby expressly waived by the applicant and the applicant's family or guardians.

By signing below, I give my consent to the San Francisco Police Activities League (SFPAL) to use the student's name, comments, photograph, and likeness in order to promote the SFPAL Chess Program.

I understand that the participant may be photographed or videotaped. I understand that the participant may be called upon by a journalist to answer questions about his or her involvement in the SFPAL Chess Program, and I will also allow the student to speak to any media via phone or in person.

Parent/ Guardian Signature and Date *

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