D2U Summer Camp Registration

Youth's Name:*

First NameLast Name

Date Of Birth:*

Date

Grade:*

FemaleMale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information:*

First NameLast Name

Cellphone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Home Number:

Please enter a valid phone number.Format: (000) 000-0000.

Email*

example@example.com

Emergency Contact:*

First NameLast Name

Relationship:*

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Does the athlete have any allergies(including food allergies/sensitivities), chronic illness or medical conditional? If yes, please describe. *

Is the athlete prescribed an inhaler? If yes, please provide any instructions.

Informed Consent & Acknowledgement:

THIS REQUEST IS ACCEPTED WITH THE UNDERSTANDING THAT THE CITY OF FORT MYERS, LEE COUNTY, THE FORT MYERS POLICE DEPARTMENT, THE FORT MYERS POLICE ATHLETIC LEAGUE, ITS AGENTS OR ITS EMPLOYEES WILL NOT BE LIABLE FOR INJURY SUSTAINED IN TRANSIT TO OR FROM ANY PAL FUNCTION, OR AS A RESULT OF PARTICIPATION IN ANY PAL ACTIVITY. INABILITY TO CONFORM THE RULES AND REGULATIONS OF PAL ON ANY PART OF THE MEMBER WILL RESULT IN THE NOTIFICATION OF THE FRACTION TO THE PARENT OR GUARDIAN. PAL RESERVES THE RIGHT TO DISMISS ANY MEMBER FOR JUST CAUSE.

Media Release:

AS PARENT/GUARDIAN, I HEREBY CONSENT THAT THE PHOTOGRAPHS AND/OR MOTION PICTURES OF VIDEOTAPE WHICH SHE/HE POSED, AND/OR AUDIO RECORDINGS MADE OF HIS/HER VOICE MAY BE USED BY THE FORT MYERS POLICE ATHLETIC LEAGUE,INC (PAL), IT'S ASSIGNEES, OR SUCCESSORS IN WHATEVER WAY THEY DESIRE, INCLUDING TELEVISION AND ELECTRONIC MEDIA. FURTHERMORE, I HEREBY CONSENT THAT SUCH PHOTOGRAPHS, FILMS, RECORDINGS, PLATES AND TAPES ARE THE PROPERTY OF PAL, AND THEY SHALL HAVE THE RIGHT TO DUPLICATE, REPRODUCE AND MAKE OTHERS USES OF SUCH AS PHOTOGRAPHS, FILMS, RECORDINGS, PLATES AND TAPES AS THEY MAY DESIRE FREE AND CLEAR OF ANY CLAIM WHATSOEVER ON MY PART.

CONFIRMATION:

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature*

My Products

D2U Camp (PAID IN FULL- 6 Wks) *Field Trips Not Included*

This will cover the 6 weeks of camp in full for ONE child. *Field Trips NOT INCLUDED*

$300.00 Quantity

D2U- One Week of Registration

D2U Camp is $50 per week. This $50 will only cover ONE week of camp.

$50.00 Quantity

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.