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2. 2019 APPLICATION CLEVELAND POLICE YOUTH ACADEMY
4. 
5. All applicants must be between 9 and 14 years of age. Child must be able to attend entire session. Any incomplete and/or unsigned applications will not be considered. This document is a public record and the information may be released by the police department without your further consent. Please type or print all information.
7. APPLICANT INFORMATION:
9. First Name*
10. Last Name*
12. Preferred Name
14. Address1*
16. City*
17. State*
18. Zip*
20. Date of Birth*
22. School Attending*
23. Grade*
25. PARENT/GUARDIAN INFORMATION:
27. Parent/Guardian First Name*
28. Parent/Guardian Last Name*
30. Address*
32. City*
33. State*
34. Zip*
36. Relationship*
38. Phone Number*
39. Email Address*
41. Parent/Guardian First Name
42. Parent Guardian Last Name
44. Address
46. City
47. State
48. Zip
50. Phone Number
51. Email Address
53. Any custody, order or other restrictions regarding custody:
55. Please list any allergies, medical conditions or prescription medications taken:
57. Are there any siblings or friends who have also applied for YPA?
59. Which Week do you wish to attend, 1st choice?
60. Which Week do you wish to attend, 2nd choice?
62. Emergency Contact Information:
    The following designate individual may act on behalf of the Parent/Guardian in case of emergency where the Parent/Guardian cannot be reached. This information must be filled out before your child can participate in the Youth Citizen’s Police Academy.
64. First Name
65. Last Name
67. Address1
69. City
70. State
71. Zip
73. Email Address
74. Phone Number
76. BACKGROUND:
78. Please explain why you want to attend the Cleveland Youth Citizen’s Police Academy and what you hope to learn if you are selected.
80. How did you hear about the Youth Citizen's Police Academy?
82. DISCLAIMER
    Cleveland’s Youth Police Academy is a comprehensive showcase of various tasks and jobs that a police officer can do. Participants will experience and be exposed to scenarios that may include, but not limited to: simulated firearms training, simulated explosions, canine interaction, drug awareness, simulated crime scene with a victim, jail and prisoners. While every interaction with police activities is done in the safest and most controlled way possible, some participants may be emotionally affected by activities. Please discuss all possible tasks a police officer may encounter and make sure your child is comfortable discussing and participating in “real-life” scenarios.
84. Please review your answers carefully and read the statement below before signing the application:
    I hereby certify there are no willful misrepresentations, omissions, or falsifications in the foregoing statements and answers to questions. I understand any omissions or false statements on this application shall be sufficient cause for rejection for enrollment or dismissal from the Cleveland Youth Citizen’s Police Academy. I further understand the Cleveland Police Department may conduct a thorough background investigation. I authorize any individual, company, organization or institution to release to the Cleveland Police Department any and all information concerning this application. I hereby release all parties and individuals connected therewith from all liabilities and for any damages whatsoever incurred for furnishing the information. I also understand any student can be expelled from the Cleveland Youth Citizen’s Police Academy if said student is disruptive or otherwise interferes with the presentation of this program. I understand all applicants will be accepted or rejected upon the sole discretion of the Chief of Police or designee. In case of a sudden illness or other serious medical emergency, if I (the undersigned parent/guardian) cannot be reached, I authorize a member of the Cleveland Police Department to take the appropriate action in seeking medical attention. I consent and authorized the City of Cleveland to record my child’s likeness and/or voice for the use by television, film, radio, digital, to include social media, or printed media to further promote the programs of the City of Cleveland and the Cleveland Police Department. I authorize the Cleveland Police Department to transport my child to and from any activities related to the Cleveland Youth Citizen’s Police Academy. This transport may be done in a city owned vehicle or a private vehicle.
86. Signature of Applicant*
    Please type your name.
87. Date*
    Date
89. Signature of Parent*
    Please type your name.
90. Date*
    Date
94. For Community Relations Unit Staff Only:
Leave This Blank:


100. 1. Receive an email copy of this form.
101. Email address

     This field is not part of the form submission.

102. Submit Submit and Print

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