Youth Police Academy

• Applicant must be between 13-17 years of age to attend the Youth Police Academy.
• Applicant must be a Lenexa resident or attend school in Lenexa or have a parent that works in Lenexa.
• Applicant must have a minimal record of school discipline and minimal police/criminal contacts.

Red fields are required.

Participant Information

First Name *

Middle Initial

Last Name *

Date of Birth *

Social Security Number *

Driver License

Driver License State

AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

School Attending (in fall of current year) *

Grade (in fall of current year) *

Employer

Participant Contact Information

Email Address *

Participant Phone

Alternate Participant Phone

Address Line 1 *

Address Line 2

City *

State *

AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code *

Session

Select Session *

June 3-7

June 10-14

Waitlist

Select Shirt Size (sizes are adult) *

S

M

L

XL

XXL

Parent/Guardian Information

Parent/Guardian Name *

Address Line 1 *

Address Line 2

City *

State *

AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code *

Home Phone

Work Phone

Cell Phone

Preferred Phone *

Home Phone

Work Phone

Cell Phone

Email

Parent/Guardian 2

Parent/Guardian Name

Address Line 1

Address Line 2

City

State

AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Home Phone

Work Phone

Cell Phone

Preferred Phone

Home Phone

Work Phone

Cell Phone

Email

Emergency Contact Information

This section is to be completed by a parent/guardian.

Contact 1

Emergency Contact Name *

Address Line 1 *

Address Line 2

City *

State *

AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code *

Emergency Contact 1 Home Phone *

Emergency Contact 1 Work Phone

Emergency Contact 1 Cell Phone

Emergency Contact 1 Alternate Phone

Preferred Phone

Home Phone

Work Phone

Cell Phone

Contact 2

Emergency Contact Name

Address Line 1

Address Line 2

City

State

AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Emergency Contact 2 Home Phone

Emergency Contact 2 Work Phone

Emergency Contact 2 Cell Phone

Emergency Contact 2 Alternate Phone

Preferred Phone

Home Phone

Work Phone

Cell Phone

Medication/Special Needs Information

This section is to be completed by a parent/guardian.

Please list any prescribed medications that your child is required to take regularly. Please indicate below whether or not your child will be required to take or carry the medication with him/her during the Youth Police Academy. *

My Child DOES take the following prescribed medications.

My child does NOT take any prescibed medication(s).

Please note the name of the medication, medical condition for which medication is needed, the dosage/administration (times per day), and any special needs or restrictions.

Essay

Please write a short essay explaining why you wish to attend the Youth Police Acadamy. Be sure to express what you hope to learn from the class. Also explain why you should be considered for the class. *

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