teen academy application .pdf
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APPLICATIONS ACCEPTED BEGINNING MAY 1, 2019
City of Oregon Police Department
TEEN ACADEMY APPLICATION
TEEN INFORMATION
Name: _________________________________________
Home Address: _________________________________
City, State, Zip: __________________________________
OH Driver’s Lic. #: ________________________________
Home Phone: (______)_______________________________
Cell Phone: (_______)________________________________
Email: _____________________________________________
Exp. Date: _________________________________________
PARENT INFORMATION
Parent 1 Name: __________________________________ Parent 2 Name: ____________________________________
Parent 1 Cell: (______)_____________________________ Parent 2 Cell: (_____)________________________________
Parent 1 Email: ___________________________________ Parent 2 Email: ____________________________________
QUESTIONNAIRE (FOR TEEN)
What school do you attend? _________________________________________________ Grade: __________________
How old are you? _______________
Have you ever been arrested or convicted of any criminal offense?
_______yes
_______no
Do you have any medical conditions that limit your activities?
_______yes
_______no
If you answered “yes” to either of the questions above, please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please let us know why you are interested in attending the Teen Academy:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ELIGIBILITY FOR ATTENDANCE IS AT THE SOLE DISCRETION OF THE POLICE DEPARTMENT
By signing below, I attest that the above information is true and correct and
I consent to a juvenile, D.M.V., and/or criminal records check.
Student Signature: _____________________________________________________________ Date: ________________
Parent or Guardian Signature: ____________________________________________________ Date: _______________
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