2. Name
   First, Middle, Last
4. Address
5. Home Phone/Cell Phone
7. School
8. Grade in 20/21 School Year
10. T-Shirt Size

    1. Adult S
    2. Adult M
    3. Adult L

    1. Adult XL
    2. Adult XXL
11. Date of Birth
    Date of Birth
12. Sex

    1. Male
    2. Female
14. Email
16. Parent/Legal Guardian
17. Home Phone/Cell Phone
19. Person to be contacted in case of emergency during your attendance at the academy:
21. Name
22. Relationship
23. Phone
25. Authorization to Conduct a Background Investigation
    The undersigned parent or legal guardian, for and on behalf of the undersigned applicant, and the undersigned applicant to the Derby Police Department Youth Citizen Police Academy, do hereby authorize the Derby Police Department to conduct a criminal history background investigation, including convictions, pending charges, post arrest and outstanding warrants of the undersigned applicant. We understand that the criminal history check is being conducted due to the nature of the classes provided at the Youth Citizen Police Academy. We understand that all available police and criminal records will be checked and that the information will be used solely for determining eligibility of the applicants for participation in the Youth Citizen Police Academy. All information is to remain confidential as required by applicable state and federal law. The undersigned parent or legal guardian and the undersigned applicant understand and acknowledge that if the applicant is accepted the applicant must comply with the rules and regulations for the program and the participation in the Youth Citizen Police Academy is a privilege and can be revoked at any time.
27. Signature of Applicant
28. Date
30. Signature of Parent or Guardian
31. Date
35. Why you are interested in attending the Derby Police Department Youth Citizen Police Academy?
37. Describe any community/recreational/extracurricular activities in which you have participated (sports, clubs, church, etc.):
39. Have you ever been convicted of any criminal law other than a traffic offense?

    1. Yes
    2. No
41. If yes, please explain.
    List description of offense, when and where it occurred.
45. Recommendations
47. List two personal recommendations who are not relatives and do not live with you (e.g. teacher, coach, principal, counselor, School Resource Officer):
    Include name, phone number, email, occupation, and school (if applicable).
51. Rules & Regulations
    Participants, either during the academy classes or during off-program times, will not engage in any inappropriate or illegal conduct. This includes criminal activity or any behavior that threatens or impacts the ability of the participant, other participants or the police department staff to conduct and participate in a safe, non-hostile environment. Participants are expected to attend all classes. Excused absences will be handled on a case-by-case basis. Unexcused absences may result in dismissal from the program. Please notify the program coordinator of any absences no later than 8:30 a.m. of that day. Any student who is tardy or late more than 20 minutes will be considered absent. Participants shall maintain a well-groomed appearance at all times. Clothing will be appropriate and not display offensive messages. Participants will come to class prepared for scheduled lessons and will bring all necessary materials. Everyone is expected to participate in discussions and activities. Failure to comply with any of the rules and regulations for the program may result in dismissal from the program.
53. Acknowledgement (Read carefully before signing)
    We, the undersigned parent or guardian and the undersigned applicant, certify that all information provided in this application is true and complete. We understand that any false information or omission may disqualify the applicant from further consideration for acceptance into the Derby Police Department Youth Citizen Police Academy and may result in dismissal of the applicant from the program, once already accepted. If accepted, we understand that the acceptance and continued participation of undersigned applicant in the Youth Citizen Police Academy is at the discretion of the Derby Police Department and participation may be terminated at any time. We have read, understand, and by our signature, agree to such terms, conditions, rules and regulations.
55. Signature of Applicant:
56. Date
    Date
58. Signature of Parent/Guardian:
59. Date
    Date
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit Submit and Print

* indicates a required field