Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
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Postal / Zip Code
Parent's Cell Phone Number
*
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Age
*
Date of Birth
*
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Month
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Day
Year
Date
School
*
Grade
*
Male or Female
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Male
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Shirt Size
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Medical Conditions
Name of Parent or Guardian
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Emergency/Alternative Contacts:
Name
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Phone Number
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Relationship
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Phone Number
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Certifications and Release of Liability:
I, the undersigned, certify that my child is at least eleven (11) years of age. I understand that falsification of any information on this form may disqualify my child from the program. In consideration for the acceptance of my child’s registration in the Junior Deputy Academy, I hereby release Calcasieu Parish Sheriff’s Office, the Calcasieu Parish School Board and their agents, employees, officers and servants from ANY and ALL damages and injuries, which may occur while my child is in the Junior Deputy Academy. I certify that I have the legal authority to execute this release on behalf of my child. By signing this document, I acknowledge that I have given my authorization for my child to attend the Junior Deputy Academy. I also understand that said minor will be subject to rules of safety and discipline as set forth by the Deputies of the Calcasieu Parish Sheriff's Office. As part of the Junior Deputy Academy, a group photo of the children will be taken. There may also be media coverage of the program as well as video to be used by the Sheriff’s Office. I authorize the photography of my child for this purpose.
Child's Name
*
Parent/Guardian Signature
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