Shawnee County Youth Academy Registration Form

Parent or Guardian Information
Parent or Guardian Name*

First NameLast Name
Parent or Guardian Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent or Guardian Email Address*
example@example.com
YesNo
Second Parent or Guardian Name

First NameLast Name
Second Parent or Guardian Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Second Parent or Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Second Parent or Guardian Email Address
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relation to Child*

Discliamers
Any food or drug allergies?
Any health or medical issues?
Is there any other information we should know about your child?
"If I cannot be reached, I hereby give permission to the Sheriff's Office personnel to seek medical attention for my child in the event of an emergency."
I hereby release and discharge the Shawnee County Sheriff’s Office, USD 345, USD 437, Seaman Middle School, Washburn Rural North Middle School, and any individual Sheriff Deputy or employee from any liability arising from accident, injury, and illness that may occur as a result of participation in this program.
I hereby authorize the Shawnee County Sheriff’s Office to publish the photographs and videos taken of my child for use in Shawnee County Sheriff’s Office printed publications, website, and social media. Neither the minor child nor I will receive financial compensation.
By typing my name below, I affirm that all acknowledgments above are true and correct*
Should be Empty:

Parent or Guardian Information