Youth Police Academy Registration

Required fields are marked with asterisks (*)

Youth Police Academy Registration

The following information is requested of all prospective participants in the Draper City Youth Police Academy program. Any false or incomplete information could exclude the applicant from participating in this program.

Student's First Name

Student's Last Name

Date of Birth

Address

City

Zip Code

Participant Cell Phone Number

Participant Secondary Phone

Participant Email

School Name

Age

Grade in August

Parent/Guardian Name

Parent/Guardian Email

Parent/Guardian Cell Phone

Parent/Guardian Work Number

Parent/Guardian Alternate Cell

Are there any custodial limitations?

Yes

If there are custodial limitations, parent must attach a current copy of court documents.

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Emergency Contact (other than parent listed above)

Relationship to participant:

Cell Phone Number

Emergency Contact's Address

This section is to be completed by the youth applicant, parent/guardian, or school counselor, teacher, or resource officer. Please indicate what motivates the applicant to attend the academy or why the applicant can benefit from attendance.

My child has permission to be dismissed from the Draper City Youth Police Academy on their own, without a parent/guardian being present at the time of dismissal.

Yes

Medication and Health History

Please be advised that your child may be offered the opportunity to observe, and/or pet a police dog, ride a bicycle, and participate in other indoor and outdoor activities. Should you wish your child not to participate in a certain activity or should your child have any special restrictions, please list below in the space provided.

Any special needs/restrictions?

Medications

NOTE: The Draper City Youth Police Academy does not stock or provide any non-prescription medications. If a participant requires the use of non-prescription medications during the program, a note to that effect must be provided by the parent/guardian in advance. Any prescription medication that needs to be carried by the participant during the YPA must be in the original prescribed packaging.

My child takes prescribed medications.

Yes

If your child takes prescribed medications, list the name of the medication(s), condition for which the medication is needed, and dosage/times per day.

Participant Health History

Please check Yes or No for each question pertaining to the applicant.

Ever been hospitalized?

Yes

Ever had surgery?

Yes

Have recurrent/chronic illnesses?

Yes

Had a recent infectious disease?

Yes

Had a recent injury?

Yes

Had asthma/wheezing/shortness of breath?

Yes

Have diabetes?

Yes

Had seizures?

Yes

Had headaches?

Yes

Wear glasses, contacts or protective eyewear?

Yes

Had fainting or dizziness?

Yes

Passed out/had chest pain during exercise?

Yes

Had mononucleosis (“mono”) during the past 12 months?

Yes

If female, have problems with periods/menstruation?

Yes

Have problems with falling asleep/sleepwalking?

Yes

Ever had back/joint problems?

Yes

Have a history of bedwetting?

Yes

Have problems with diarrhea/had a recent infectious disease?

Yes

Have any skin problems?

Yes

Traveled outside the country in the past 9 months?

Yes

Ever been treated for attention deficit disorder (ADD) or attention deficit /hyperactivity disorder (AD/HD)?

Yes

Ever been treated for emotional or behavioral difficulties or an eating disorder?

Yes

During the past 12 months, seen a professional to address mental/emotional health concerns?

Yes

Had a significant life event that continues to affect the youth’s life? (history of abuse, death of a loved one, family change, adoption, foster care, new sibling, survived a disaster, others)

Yes

Please explain “Yes” answers in the space below. For travel outside the country, please name countries visited and dates of travel. The DCYPA may contact you for additional information.

Health Care Providers

Name of primary doctor

Primary doctor's phone number

Name of dentist

Dentist's phone number

Name of orthodontist

Orthodontist's phone number

Additional Health Information

Please provide in the space below any additional information about the youth’s health or otherwise that you think important that we know or that may affect the participant’s ability to fully participate in the DCYPA program.

I attest that my child has been fully immunized and that his/her immunizations are current and up-to-date. I agree to accept all risks to my child if not fully immunized.

Clear

In case of a medical emergency, I authorize the Draper City Police Youth Academy to initiate emergency care in the event that I cannot be reached.

Clear

Waiver

As parent/guardian named in this application, I hereby give permisson and authorization for the participant named in this application

TO PARTICIPATE IN THE DRAPER CITY YOUTH POLICE ACADEMY INCLUDING PHYSICAL TRAINING/EXERCISE/SPORTS, FIREARMS AWARENESS, ALL THE ACTIVITIES OUTLINED IN THE CALENDAR OF EVENTS, AS WELL AS TRANSPORTATION TO AND FROM SAID EVENTS AND CONSENT FOR PHOTOGRAPHY/VIDEOTAPING/INTERVIEWS.

THE UNDERSIGNED HEREBY RELEASES AND DISCHARGES THE CITY OF DRAPER, INCLUDING THE DRAPER CITY POLICE DEPARTMENT, AND THEIR AGENTS AND EMPLOYEES THEREOF, FROM ALL LIABILITY CLAIMS AND CAUSES OF ACTION THAT THE UNDERSIGNED MAY HAVE FOR PERSONAL INJURIES, DAMAGES OR LOSSES OF ANY NATURE, WHICH MAY RESULT, OR OCCUR AS A RESULT, OF PARTICIPATION IN THIS PROGRAM AND IN ANY CAPACITY OR FUNCTION AS A YOUTH ACADEMY PARTICIPANT.

THE UNDERSIGNED FURTHER AGREES TO HAVE THEIR CHILD OBEY DIRECTIVES OF YOUTH ACADEMY INSTRUCTORS, POLICE OFFICERS OR THEIR DESIGNEES WHILE ACCOMPANYING SAID OFFICER. ADDITIONALLY, PARTICIPATION IN THE PROGRAM CAN BE RESCINDED AT ANY TIME DURING THE COURSE OF THE ACADEMY WITHOUT CAUSE AND IS IN THE SOLE AND ABSOLUTE DISCRETION OF THE PROGRAM DIRECTOR/INSTRUCTORS.

THE UNDERSIGNED FURTHER PERMITS THE DRAPER CITY POLICE DEPARTMENT TO PRINT OR DISPLAY ANY PHOTOGRAPHS OF ANY CHILD IN DRAPER CITY YOUTH POLICE ACADEMY ACTIVITIES ON THE DRAPER CITY WEBSITE AND/OR PRINT RELEASES OR IN MEDIA COVERAGE OF THE DRAPER CITY YOUTH POLICE ACADEMY PROGRAM.

THE UNDERSIGNED FURTHER ATTESTS THAT MY CHILD HAS NO PHYSICAL RESTRICTIONS AND/OR LIMITATIONS AND MAY PARTICIPATE IN ALL ACTIVITIES RELATING TO THE DRAPER CITY YOUTH POLICE ACADEMY INCLUDING STRENUOUS PHYSICAL ACTIVITIES.

I HEREBY ATTEST TO HAVING READ THIS DOCUMENT AND THE CALENDAR OF EVENTS AND ACKNOWLEDGE THE UNDERSTANDING THEREOF.

Parent/Guardian Signature Accepting Terms of Waiver

Clear

Final Parent/Guardian Signature

Parent/Guardian Signature - By my signature I acknowledge that I have reviewed this application in its entirety, that all the information I have provided is accurate and complete, and I request that the applicant be considered for acceptance.

Clear

Date

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