San Francisco Police Activities League Judo Program

Personal Health and Medical Form

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

Participant 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

Health Insurance Provider *

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 *

Medical History

Date of Last Physical Examination * +

Are you aware of any current health problems? *

Yes

No

Are you currently under medical care or taking medications? *

Yes

No

Have you had any surgery, injury, illness, allergy or change in health status since the last complete physical examination? *

Yes

No

Has it ever been necessary to restrict the applicant's activities for any medical reason? *

Yes

No

Does the applicant have a learning disability? *

Yes

No

Please check all the applicable *

Give details to items checked above. If not applicable, please enter N/A. *

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. *

List any medications taken *

Medical Release

In the event of illness or injury occurring to my son or daughter while involved in this activity, I consent to X-ray examination, anesthesia, and/ or surgical diagnostic procedures or treatment considered necessary in the best judgment of the attending physician and performed by or under the supervision of a member of the medical staff of the hospital furnishing medical services. It is understood that in the event of a serious illness or injury, reasonable efforts to reach me will be attempted.

Insurance Company *

Policy and Group Number *

Personal Physician *

Phone Number of Physician *

Parental Statement

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

Parent/ Guardian Signature and Date *

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Parent/ Guardian Approval

Parent/Guardian First and Last Name *

Address, City and Zip *

Phone Number for Parent/ Guardian *

Parents/Guardians Must Read and Sign the Statement Below

PAL Judo Program

The PAL Judo Program is a strenuous program that requires children to engage in physical activity. Although injuries are rare and reasonable efforts are taken to plan and supervise a safe activity, the nature of participating in the below-listed activities is not without risk.

Acknowledgment of Risks

This is a partial list of possible hazards of participating in this activity. Most of the injuries are rare, however, some have occurred and you need to know about them. Activities may be strenuous and include calisthenics, stretching, kicking & punching drills, throwing, grappling, joint locks, and sparring in a controlled and supervised environment. These activities could cause the participant various injuries: Strenuous activities may cause shortness of breath, strained or pulled muscles, dislocated joints, or broken bones. Exposing oneself to strenuous physical activity may cause injury, illness, or, in extreme cases, permanent trauma or death.

Agreement

I hereby approve and agree to all of the terms and conditions and certify that this applicant can meet the activity's health and physical fitness requirements.

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, 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, including preliminary training and travel, are hereby expressly waived by the applicant and the applicant's family or guardians.

Parent/ Guardian Signature and Date *

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San Francisco Police Activities League Media Waiver Form

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 to promote the PAL Judo Program.

I certify that I am the (check one) *

Participant (over age 18) with the right to give consent

Legal Guardian of the Participant (under age 18) with the right to give consent.

I understand that the participant may be photographed or videotaped. I understand that a journalist may call upon the participant to answer questions about his or her involvement in the PAL/ SFPD JudoProgram, and I will also allow the student to speak to any media via phone or in person.

Participant Name *

Parent/Guardian Name *

Parent/ Guardian Signature and Date *

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