Please complete the application for the November 9, 2019 Teen Citizen Police Academy.* Full name * Address * Name of parent/guardian * Phone * Emergency contact * E-mail * Date of birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year20022003200420052006 Year Grade level * Sex * Male Female Other... Sex Other... Height * Eyes * Brown Blue Green Hazel Other... Eyes Other... Hair * Brown Black Blonde Red Other... Hair Other... OL # (if applicable) Have you ever been arrested/convicted of a crime? * Yes No If you answered "yes" above, explain. Do you need any special accommodations due to a disability? Yes No If you answered "yes" above, please let us know which accommodations. In consideration of the Winchester Police Department granting permission to enter in or upon any premises which are under actual care or passive control, I hereby waive all claims to damage or loss to my person or property which may be caused by any act or failure to act of the Winchester Police Department, its officers, agents or employees. I assume the risk of all dangerous conditions in or, upon the premises or vehicles, and waive any and all notice of existence of such conditions. I certify that I understand the requirements and responsibilities of participants in this program. * I understand Applicant signature (type name) * Parent/guardian signature (type name) * Date of submission * MonthDec Month Day9 Day Year2019 Year Leave this field blank Submit *A check will be conducted on applicants prior to attending. Previous misconduct may disqualify an applicant from participation.