Arlington Heights Police Department

Youth Police Academy Sign Up Form

This application and related documents must be filled out by both the parent and the prospective student. The submission of this application does not guarantee acceptance into the Youth Police Academy. All questions must be answered truthfully; any falsifica-tion may be grounds for dismissal from the program. Candidates shall not be excluded due to race, gender, sexual orientation, national origin, or religious affiliation. Parents will be contacted via email with acceptance confirmation.

Information About Youth Academy Applicant

Applicant's Gender

Applicant's School

Applicant's Grade Level Completed

Applicant's Email

Why do you want to attend the Youth Citizen Police Academy?

Parent/Guardian Emergency Contact Information

Relationship to Applicant

Place of Employment (In the event of an emergency)

Primary Phone Number

Work Phone number

Email Address

Additional Emergency Contact (if above is unavailable) Please provide name and phone number.

Has the Applicant Student ever been arrested?

Yes

Has the student been expelled, suspended, or had more than three office referrals during the last year?

Does the applying student have any medical conditions or allergies?

Photo Release

If accepted to the program, I give parental/guardian consent to use any photograph taken or digital image captured of my child/ward during their participation in the Arlington Heights Youth Citizen Police Academy for use in future Academy brochures, social media, website, and news outlets.

Checkbox/Radio Group

Grant Consent

Authorization of Background Check

By submitting the below signature, I authorize the Arlington Heights Police Department to conduct a personal background check based on this application. The sign-ing of this application and related paperwork attests that you, as a legal guardian of the student, and the student, agree to adhere to all the guidelines, requirements, rules of conduct and release the Village of Arlington Heights Police Department and all agents free from liability.

Sign Here

First Name

Last Name

Choose how to sign

Draw Type