Law Enforcement Training Academy/Virginia Beach Sheriff’s
Office DARE Home School Registration Information
Session: July 9-20
Student’s Full Legal Name:________________________________________
Grade:_________
Male____ Female______ Date of Birth:____________ Age______
Student’s Primary Nighttime Residence_____________________________________ Apt #___
City: ______________________________________________ State:______ Zip Code:________
Pare t(s)/Guardian(s) (If Guardianship/Custody: Please provide legal documentation)
(Last, First, MI):_________________________________________________ Relation:________
Primary address:___________________________ City:________________State:_____ Zip:___
Primary Phone:________________ Secondary Phone:_____________E-Mail:_______________
Stu Live With: ___No ___Yes Custody: ___No ___Yes Educ. Rights: ___No ___Yes
Contact Allowed: ___No ___Yes
Employment Address: ___________________________________________________________
City:____________________________ State____________ Zip Code:_____________________
(Last, First, MI):_________________________________________________ Relation:________
Primary address:___________________________ City:________________State:_____ Zip:___
Primary Phone:________________ Secondary Phone:_____________E-Mail:_______________
Stu Live With: ___No ___Yes Custody: ___No ___Yes Educ. Rights: ___No ___Yes
Contact Allowed: ___No ___Yes
Employment Address: ___________________________________________________________
City:____________________________ State____________ Zip Code:_____________________
(Last, First, MI):_________________________________________________ Relation:________
Primary address:___________________________ City:________________State:_____ Zip:___
Primary Phone:________________ Secondary Phone:_____________E-Mail:_______________
Stu Live With: ___No ___Yes Custody: ___No ___Yes Educ. Rights: ___No ___Yes
Contact Allowed: ___No ___Yes
Employment Address: ___________________________________________________________
City:____________________________ State____________ Zip Code:_____________________
(Last, First, MI):_________________________________________________ Relation:________
Primary address:___________________________ City:________________State:_____ Zip:___
Primary Phone:________________ Secondary Phone:_____________E-Mail:_______________
Stu Live With: ___No ___Yes Custody: ___No ___Yes Educ. Rights: ___No ___Yes
Contact Allowed: ___No ___Yes
Employment Address: ___________________________________________________________
City:____________________________ State____________ Zip Code:_____________________
Parent/Guardian Military Connection (Check one) Military Information (Active Duty Only)
__Non government nor military connected
Rate/Rank:________________________
__ Government Connect-not active duty military i.e. Contractor:_______________________
__ Military-lives on base-Name of base:____________________ base/homeport:__________
__ Military- lives off base
______________________________________________________________________________
Information Concerning Discipline or Criminal/Delinquent Acts
PELASE COMPLETE AND SIGN THE APPLICABLE STATEMENT BELOW
______1. Has the student been expelled from school attendance at a private or public school
In the commonwealth or in another state for an offence in violation of School Board Policies
relating to weapons, alcohol, drugs or for the willful infliction of injury to another person?
Law Enforcement Training Academy/Virginia Beach Sheriff’s
Office DARE Home School Registration Information
Session: July 9-20
Student’s Name:________________________________________ Date of Birth:____________
Doctor’s name:_________________________________________ Phone #:________________
Adult emergency Contact Information (other than parent/guardian) – In the event of an
emergency, during D.A.R.E. school hours that my child may be released to one of the adults
listed below:
Name:_______________________________________ Relation:_________________________
DOB: _________ Street Address:___________________________________________________
Primary Phone:________________ Cell Phone:_____________ Alternate:____________
Name:_______________________________________ Relation:_________________________
DOB: _________ Street Address:___________________________________________________
Primary Phone:________________ Secondary Phone:______________ Alternate:___________
Childcare Provider (If applicable):__________________________________________________
DOB: _________ Street Address:___________________________________________________
Address: ____________________________________________________Phone:____________
The person listed above will be required to show a form of ID issued by a Government agency.
Do you have health insurance for this student: ___Medicaid ___ Military __FAMIS ___Private
Does this student have any medical problems we need to be aware of? ___Yes ___No
Please list them________________________________________________________________
_____________________________________________________________________________
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If we are unable to contact parent/guardian, I give my permission for the Law
Enforcement Training Academy to contact my child’s physician for clarification of any
medical needs.
I give Law Enforcement Training Academy authorities permission, to secure necessary
aid and transportation for the preservation of my child’s health, at my expense.
Signature of Parent or Legal Guardian:_______________________________ Date:__________