Youth Citizen Police Academy Application

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Peoria Police Department Youth Citizen Police Academy
Application, Liability Waiver, Rules and Regulations
Must be submitted no later than Friday, May 10th, 2019
This is a FREE program. Students must be entering 7th or 8th Grade in the fall of
2019. The student must reside or attend school within the Peoria city

Please correct the field(s) marked in red below:

Student's Name
Select One
Select One
Date of Birth
Phone Number
What grade will the student be entering in the Fall of 2019? 
What grade will the student be entering in the Fall of 2019?
Select Adult T-Shirt Size
Select Adult T-Shirt Size
Parent / Guardian Name 
Parent / Guardian Daytime Phone Number 
Parent / Guardian E-mail Address  
2nd Parent / Guardian Name 
2nd Parent / Guardian Daytime Phone Number 

Please choose which week / time you child would like to attend, please make sure your first choice and second choice are different. After you submit the application, you will be advised by e-mail of your class placement. Placement in your first choice is not guaranteed.


Please choose your FIRST choice for which session your child would like to attend


Please choose your FIRST choice for which session your child would like to attend **SUNRISE MOUNTAIN IS FULL**

Please choose your SECOND choice for which session your child would like to attend


Please choose your SECOND choice for which session your child would like to attend **SUNRISE MOUNTAIN IS FULL**
Emergency Contact 
Emergency Contact Phone Number
Doctor's Name 
Doctor's Phone Number
Please list any conditions that could restrict activities (i.e. diabetes, asthma, heart, etc.) or any other
condition (hyperactivity, ADHD, etc.) of which Academy staff should be made aware. (This
information will be held in the strictest confidence.)
List any allergies your child has (food, medications, etc.)
List any issues your child may have while participating in physical fitness.
List the means by which your child will arrive at and depart from school (i.e., walk, bicycle, dropped
off by parent, etc)
List any other persons authorized to pick up your child
List any child custody issues that the Academy staff would have a reasonable interest in.
How did you hear about the Youth Citizen Police Academy?
How did you hear about the Youth Citizen Police Academy?

There will be no medical staff on campus during this Academy and staff will not administer medications. In the unlikely event of an emergency, the Peoria Fire Department will be contacted. In addition, if we are unable to contact you in the event of an emergency, the Academy staff will take all reasonable measures deemed necessary.


Peoria Police Department Waiver of Liability



I, ________________________, being the parent or legal guardian of _________________________, do hereby
agree to the terms of this release and do give my full consent for his/her participation in the Peoria Police Activities
League Youth Citizen Police Academy. I affirm that this application contains no misrepresentations or falsifications,
omissions, or concealment of material fact, and that the information given by me is true and complete to the best of my
knowledge and belief.


I/we hereby release and forever discharge the City of Peoria, the Peoria Unified School District #11 and the Peoria
Police Department, its elected and appointed officials, directors, officers, boards, commissions, agents,
representatives, servants, and employees, and any and all other persons, firms, or corporations who are or might be
liable, from any and all claims of any kind or character which I/we have or may have against them due to my/our
child’s participation in any events, classes, demonstrations, etc., at this Academy offered by the City of Peoria and the
Peoria Police Department. This waiver includes all damages, losses, costs, expenses and injuries that allegedly occur
during the course of the Academy. In that regard, I/we agree to indemnify, defend and hold harmless to the fullest
extent permitted by law the foregoing persons and entities from any loss or damages, including reasonable attorney's
fees and litigation expenses, which may be incurred by them in the event any such claims are asserted against any of
them. I/we understand that medical claims are my/our responsibility. I/we understand that photographs and/or video
may be taken of my child during the course of the Academy. I/we authorize the use of any photograph or video taken
of my child to be used by the Peoria Police Department for purposes of pamphlets, local print and television news
and/or on the Peoria Police Department website. Photographs will not be sold for any purpose. This waiver does not
extend to any such claim or liability that is caused by the sole and exclusive intentional acts or gross negligence of the
City of Peoria, the Peoria Unified School District and the Peoria Police Department or its officers, employees or


Parent or Guardian will sign on the first day of the Academy. 

***Please note, you will need to present a picture identification with you when you pick up
your child from the Youth Citizen Police Academy each day.

Rules and Regulations
Academy Behavior Policy

It is our intention to provide your child with a safe and secure environment. We will attempt to create a warm, comfortable, and fun atmosphere that will have your child looking forward to coming to the Academy each day.


We are here for your child and the other children to have a positive experience. The Academy behavior policy, outlined below, will help children and our staff to understand and enforce the rules fairly. Our program stresses good citizenship with an emphasis on the following:


1. Always tell the truth.
2. Safety.
3. Cooperation and participation are both required in activities.
4. Respect those around you, both students and staff, be nice to others; no negative comments or put-downs.
5. Respect for property.
6. Appropriate language and dress at all times; inappropriate language (e.g. degrading, profane, racial slurs, etc.) will not be tolerated.
7. Keep your hands to yourself; hitting, pushing or shoving will not be tolerated.
8. Do not borrow from others without permission.
9. Be a good sport.


Please be advised, the following behaviors will detract from a positive Academy experience: physical aggression, stealing, defiance in following instructions, and/or repeated incidents of inappropriate language.


If a student has difficulty with our behavior program, our first response will be to verbally intervene and help your child understand the impact his/her behavior is having on the positive Academy experience. If the behavior continues to be disruptive, his/her parent/guardian will be contacted to pick up their child. The child will then be asked to not return for the remainder of the day and possibly for the remainder of the Academy, depending on the nature of the behavior issue. Academy staff will record the incident and outline the consequences of the behavior with the student and his/her parent/guardian.


Each parent or guardian of the youth must sign a Waiver of Liability Clause. There are no exceptions to this requirement. Please do not bring any children or guests with you who are not registered Academy participants.


Students will not leave the Academy without notifying the Academy staff, unless the day’s session has ended.


For your safety and the safety of others, the use of skateboards, roller blades, scooters, motorized play vehicles, etc. is prohibited on school property.


Good health and safety practices must be observed at all times.


All accidents or illnesses must be reported immediately to the Academy staff.


The drinking of alcohol or the use of drugs or tobacco on and off campus is strictly prohibited. The violation of this rule is just cause for immediate dismissal.


No knives, firearms, or weapons are permitted on the campus. The violation of this rule is just cause for immediate dismissal.


No food or drink is allowed in the classroom(with the exception of drinking water).


Drop off / arrival time is between 7:45 AM and 8:00 AM each day for the morning session and between 12:45 PM and 1:00 PM for the afternoon session. Tardiness is discouraged.


Pick up / departure time is 12:00 PM (sharp) for the morning session and 5:00 PM (sharp) for the afternoon session. You will be required to show a picture identification when picking up your child.


Students will be permitted to arrive or leave the Academy by vehicle, bicycle, or walking. Bus transportation will not be provided.


Students need to wear comfortable shoes every day. Flip-flops, sandals, and other open- toed shoes are not permitted.


Academy shirts will be provided on Monday.


Do not bring valuables to the Academy (CD players, IPODs, large amounts of money, radios, etc.)


Cell phones are permitted; however, these devices will be turned off during classroom instruction. Texting and any other communication will not be permitted during classroom instruction.


Each student will receive a water bottle on Monday. It is the student's responsibility to keep his/her water bottle all week.


Participation and some physical / hands-on activity will be encouraged.


Children will not shoot real firearms, but may handle inoperable demonstration weapons.


*In any situation not specifically covered by the above rules, the decision of Academy Director is final and must be followed.

  1. To receive a copy of your submission, please fill out your email address below and submit.