Clone of Youth Academy Registration Form

STPD Youth Police Academy Registration

STAFFORD POLICE 2026
July 6th-10th, 2026

Cadet Must be entering 6th or 7th grade in the Fall of 2026
Cadet Information
Cadet Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
T-Shirt Size*

Youth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XL
Short Size*

Youth MediumYouth LargeYouth XLAdult SmallAdult MediumAdult LargeAdult XL
Parent/Guardian Information
Name*

First NameLast Name
Home Number*
Format: (000) 000-0000.
Cell Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Format: (000) 000-0000.
Alt. Phone Number*
Format: (000) 000-0000.
Does the recruit have any allergies, chronic illness, or medical conditions? If yes, please describe.*
Is the recruit prescribed an inhaler? If yes, please explain any instructions.*
Media Release Consent

I grant permission for the Stafford Township Police Department and its subordinates, to use my son or daughter’s name and/or photographs for use in any media publications, or newsletters. I hereby waive any right to inspect or approve the finished photographs or printed or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the photograph.

I hereby agree to release, defend, and hold harmless the Stafford Police Department and subordinates, including any firm publishing and/or distributing the finished product in whole or in part, whether on paper or via electronic media, from and against any claims, damages or liability arising from or related to the use of the photographs, including but not limited to any misuse, distortion, blurring, alteration, optical illusion or use in composite form, either intentionally or otherwise, that may occur or be produced in taking, processing, reduction or production of the finished product, its publication or distribution.

I certify that I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.
By Signing you consent to the above media release.*
Date*

MonthDayYear
Date
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Stafford Twp Police during the selected camp. In exchange for the acceptance of said child’s candidacy by Stafford Twp Police ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Stafford Twp Police . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Stafford Twp Police . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Stafford Twp Police . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date*

MonthDayYear
Date
Signature*

Payment*

Youth Academy Registration

$200.00

Enter coupon

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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STPD Youth Police Academy Registration

July 6th-10th, 2026

Cadet Information