Dallas Junior Police Academy Enrollment Application, Waiver & Release
For Saturday, November 8, 2014
For Students in 4th, 5th, 6th and 7th Grade
PLEASE COMPLETE THE FOLLOWING INFORMATION.
PRINT CLEARLY. THIS IS OUR ONLY WAY TO CONTACT YOU.
Student’s Name:
Parent/Guardian Phone:
Parent/Guardian Name:
Cell Phone:
Student’s Email:
Parent’s Email:
Address:
Date of Birth:
City/Zip Code:
Last 4 digits of Student’s Social Security Number:
School Attending:
Grade in School:
Grade Point Average:
City Where School Is Located: _________________________________________________________________________
Do you have any food allergies? Yes_____ No ______
If yes, please provide explanation: _____________________________________________________________________
Has the applicant ever been arrested for, convicted of, or cited for an offense? Yes
If yes, on a separate sheet of paper, give dates and explain charges, places and actions taken.
No
Please review your answers carefully and read the statements below before signing this application.
I (We) hereby certify that the above statements are true and correct, and there are no willful misrepresentations, omissions or
falsification in the foregoing statements and answers to questions. I (we) understand that any omission or false statement on this
application shall be sufficient cause for rejection of enrollment or dismissal from the Junior Police Academy. I (We) understand the
goal and purpose of this program is to educate students regarding the purpose, rationale and context of police procedures, and
not to train anyone to be a police officer. I (We) acknowledge that as part of acceptance to this program, the student will be
required to attend the full session. Failure to attend the full session will be cause for dismissal from this program. I (We) will abide
by all rules and regulations set forth by the Dallas Police Department and the City of Dallas. I (We) further understand that the
Dallas Police Department will be conducting a thorough background investigation.
Date:
Applicant’s Signature
Date:
Parent’s or Legal Guardian’s Signature
You can learn more about the Dallas Junior Police Academy and watch a video of the class on our website: DallasJPA.org. For
additional information go to http://www.dallaspolice.net/jointheteam.html.
To all Parents:
The Dallas Junior Police Academy is a full-day learning experience sponsored by the Dallas Police Department. The purpose of
this event is to provide education/information to the students who attend. Those attending will leave with a realistic view of law
enforcement and the opportunities a career in law enforcement would afford. During the day, the students will enjoy a “hands on”
experience of the Police Academy, learn about the equipment in a Police patrol car, and have one-on-one interaction with law
enforcement professionals.
You will be notified when the student’s application has been accepted to participate in the
Dallas Junior Police Academy. If you have NOT been notified, your child is not able to
attend this class. You will need to reapply for the next class.
If you are accepted and cannot attend, it is very important to let us know. A “no show”
means another student that is on the waiting list is unable to attend the class.
A class will be held on Saturday, November 8, 2014. 80 students will be selected for each class. They must be in the 4th, 5th, 6th,
or 7th grade. Classes will be at the Dallas Police Academy, 5310 Red Bird Center Drive, Dallas, Texas 75237.
Students are to wear school-appropriate attire: shirts with inappropriate language, shorts, sandals, flip-flops or tank tops WILL
NOT BE PERMITTED. Students will be outside part of the day and should dress accordingly, including comfortable
walking/exercise shoes. If the student has any food allergies, they should be noted on the application. All students will be required
to check in between 8:00 AM and 8:30 AM. The Academy will begin at 9:00 AM. They will be welcomed by a Chief of the Dallas
Police Department. Lunch will be provided. At 4:45 PM, parents are invited to attend the graduation of their students from the
Dallas Junior Police Academy. The graduation will conclude at 5:15 PM, and certificates will be awarded. There will also be a
drawing for an Apple IPOD Shuffle and other special prizes for the students.
$5.00 Pizza lunch to be paid by student at check-in. Scholarships are available.
Transportation is not provided. Upon arrival, parents/guardians will be responsible for
registering their child and providing verification of transportation at the end of the day. No
child will be allowed to leave with anyone other than their parent/guardian without prior
Waiver
and
Release
written approval from their parent/guardian
and
showing
the proper ID at the time of pickup.
I recognize that the activity for which I am registering my child/participant involves a risk of injury, as does any athletic activity. I
waive and release any and all rights and claims for injury or damages resulting from this event or any safety equipment given to a
participant by members of this event. I agree to hold harmless the City of Dallas/Dallas Police Department and all volunteers and
event staff members for any and all injuries suffered by me or my child while participating in this activity. I also agree to hold
harmless all the above for any damage to my personal property related to my participation in this event.
Date:
Student’s Name
Date:
Parent’s or Legal Guardian’s Signature
Printed Name of Parent or Guardian
_____ Please check this box if you DO NOT give us permission to use the student’s photograph.
THESE CLASSES FILL UP VERY QUICKLY, SO GET YOUR APPLICATION IN AS SOON AS POSSIBLE!
APPLICATIONS ARE AVAILABLE AT: dallaspolice.net and dallasjpa.org
Send application to:
Sgt. Cheryl Cornish, #6417
Youth Outreach Unit (Y.O.U)
Dallas Police Department
1400 S. Lamar Street
Dallas, Texas 75215
Phone: 214-671-3029
Fax: 214-670-8689
NEW e-mail: info@dallasjpa.org
website: dallasjpa.org
twitter: @DallasJrPolice
Revised: 9-28-14