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2. Name (First, Middle, Last)*
4. Date of Birth*
6. Address*
8. City*
9. State*
10. Zip Code*
12. Gender (Male or Female)*
13. Phone Number*
15. Email Address*
16. Shirt in Adult Size*
    Small, Medium, Large, Extra Large, Double Extra Large)
18. Parent or Guardian Name*
19. Relationship to Student*
21. Is the student living with them?*
22. School You Are Attending*
24. Additional Info on child that instructors should know:
26. Grade you will be in (Fall 2024)*
27. Emergency Contact Name*
29. Emergency Contact Home Phone*
30. Emergency Contact Cell Phone*
32. Briefly tell us how you heard about the Junior Police Academy*
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field