Justice Academy Enrollment Form

Justice Academy

An Initiative of the Kankakee County State's Attorney's Office
Participant's Information
Student's First and Last Name*
Birth Date*
School *
Grade*
Student ID# (offline only): ___________________
Gender

MaleFemale
Ethnicity

WhiteAsianHispanic or LatinoNative Hawaiian or other Pacific IslanderAfrican American/Black
Primary Language
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Cell Number*

Area CodePhone Number
E-mail*
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*

Area CodePhone Number
Informed Consent, Waiver and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by the Kankakee County State's Attorney's {Organization} during the selected camp. In exchange for the acceptance of said child’s candidacy by Justice Academy, I achkowledge my child is a Kankakee County resident and I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the Justice Academy, Kankakee County, Kankakee County State's Attorney's Office, District 111 Board of Education and all its respective officers, agents, and representatives from any and all liability for injuries or incidents to said child arising out of traveling to, participating in, or returning from selected activities.

Also, I hereby grant permission to the Justice Academy with the right to use, reproduce, and/or distribute any photographs, film, video-tapes and sound recordings of me and my child, without compensation or approval rights, for use in materials created for purposes of promoting the future activities of the Justice Academy.
Signature

Clear
If an employee is filling out this form Sign Here
Thank you for registering your child for The Justice Academy's After-School Program. A Co-Director will be in touch to provide you with the enrollment forms to fill out and sign so please include your email address. In the event capacity is reached, your child will be put on a waiting list and we will contact you at the number provided as positions become available.
Should be Empty: