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2. Teen Police Academy Application
4. Last Name*
5. First Name*
7. Date of Birth*
   Date of Birth
8. Home Street Address*
10. City*
11. State*
13. Zip Code*
14. Primary Phone*
16. Alternate Phone
17. Email Address
19. School*
20. Grade Level*
22. Driver's License Number
23. Driver's License State
25. Parent / Guardian Name*
26. Parent / Guardian Phone*
28. Parent / Guardian Email Address*
32. Background
34. Have you been arrested/taken into custody?*

    1. Yes

    1. No
36. If yes, please provide details:
38. Have you ever been in trouble at school?*

    1. Yes

    1. No
40. If yes, please explain:
42. Why do you wish to attend the Citizen Police Academy?*
46. Occupation
48. Your Occupation
49. Work Address
51. Work City
52. Work Zip Code
Leave This Blank:


54. 1. Receive an email copy of this form.
55. Email address

    This field is not part of the form submission.

56. Submit

* indicates a required field