MISSOURI STATE HIGHWAY PATROL YOUTH ACADEMY PROGRAM June 11 - June 17, 2017 Sunnyhill Adventures - Dittmer, Missouri APPLICANT NAME: (Last) (First) (Middle) ADDRESS: CITY: STATE: ZIP: EMAIL ADDRESS: AGE: SEX: M (CIRCLE ONE) F DATE OF BIRTH: PARENT / GUARDIAN NAME, CELL & HOME NUMBER: NAME: CELL: ( ) HOME: ( ) EMAIL ADDRESS: T-SHIRT SIZE: S M L XL XXL (SIZES CANNOT BE CHANGED) (CIRCLE ONE) GRADE / SCHOOL ATTENDING IN FALL HOW DID YOU HEAR ABOUT THE YOUTH ACADEMY PROGRAM? EXTRACURRICULAR ACTIVITIES: APPLICATIONS WILL BE TAKEN ON A FIRST-COME BASIS Check-in time will be Sunday, June 11th, at 12:30 P.M. at the Maryland Heights Community Center, 2300 McKelvey, Maryland Heights, MO 63043. FURTHER INSTRUCTIONS WILL BE IN ACCEPTANCE PACK
MEDICAL INFORMATION The Missouri State Highway Patrol Youth Academy Program will include a multitude of physical activities including but not limited to: daily fitness exercises (push-ups / running / jumping; water activities such as swimming; obstacle courses; zip-line; high ropes challenge course). Applicants should possess a reasonable fitness level. GENERAL HEALTH CONDITION: EXCELLENT GOOD *POOR *(If poor, please explain) Indicate all prior or present injuries to the participant which may hinder or restrict his / her participation in the physical training program or any other physical activities. Please list all allergies including medicines, antibiotics, bee stings, insect bites, poison ivy or foods that will require attention. ALL MEDICATIONS MUST BE KEPT IN ORIGINAL PRESCRIPTION BOTTLE / PACKAGING. MEDICATIONS WILL BE MANAGED AND ADMINISTERED BY THE CAMP STAFF. PLEASE LIST ALL MEDICATIONS: *I RECOMMEND FULL PHYSICAL ACTIVITY, UNLESS OTHERWISE SPECIFIED.* _ SIGNATURE OF PARENT/GUARDIAN
NON-PRESCRIPTION MEDICATION / AIDES The following items will be available during the camp from the staff. In order to provide these medications to your child, indicate the use of what specific item(s) he/she may take. Any medication not checked yes or no will be considered a no. YES NO YES NO Tums Ibuprofen Imodium AD (Adult) Sunscreen Tylenol Caplets (Adult) Mosquito/Bug Spray Neosporin Benadryl has my permission to take the (PRINTED CADET NAME) above medications / aides if needed. (SIGNATURE OF PARENT/GUARDIAN) MEDIA RELEASE PARENTS: Do we have permission for pictures and videos of your child, taken during camp activities, to be published in local newspapers and used for future Missouri State Highway Patrol Youth Academy Program promotions, articles, and social media accounts such as Facebook and Twitter? *** All Cadets will be pictured in the Youth Program group photo. YES, YOU HAVE MY PERMISSION FOR PHOTOS AND VIDEOS TO BE USED FOR THE ABOVE PURPOSES: (SIGNATURE OF PARENT/GUARDIAN) TRANSPORTATION I hereby grant permission for the Missouri State Highway Patrol s Youth Academy Program to provide transportation for my child. (SIGNATURE OF PARENT/GUARDIAN)
MISSOURI STATE HIGHWAY PATROL YOUTH ACADEMY PROGRAM EMERGENCY CONTACT INFORMATION CADET NAME:,, (LAST) (FIRST) (MI) PARENT #1 NAME:,, (LAST) (FIRST) (MI) HOME: ( ) WORK: ( ) CELL: ( ) PARENT #2 NAME:,, (LAST) (FIRST) (MI) HOME: ( ) WORK: ( ) CELL: ( ) ADDITIONAL NAME:,, (LAST) (FIRST) (MI) HOME: ( ) WORK: ( ) CELL: ( ) INFORMATION FOR PARENTS / GUARDIANS 1.) Send completed (signed) application package, COPY OF PARTICIPANT S MEDICAL INSURANCE CARD, and graduation RSVP by May 15th to: Sergeant Bob Parr Missouri State Highway Patrol 891 Technology Drive Weldon Spring, MO 63304 2.) Selection and notification of participants will be made by mail no later than May 26th. Included in the selection package will be further instructions and information on the camp, including check-in and graduation information, as well as a packing list for participants. 3.) If there are any questions about the Missouri State Highway Patrol Youth Academy Program, you may contact Sergeant Bob Parr, Camp Coordinator, at (314) 304-6357, or by email at robert.parr@mshp.dps.mo.gov.
MISSOURI STATE HIGHWAY PATROL YOUTH ACADEMY PROGRAM Consent to Participate Parent s Consent / Release From Liability I, give my consent for my son/daughter (Parent / Guardian Printed Name) to participate in the Missouri State Highway (Cadet Participant Printed Name) Patrol s Youth Academy Program. I understand that every effort will be made to ensure the safety of my son/daughter. I understand that they will be receiving training related to law enforcement topics, as well as taking part in supervised role playing activities. Additionally, daily activities will include various physical fitness activities as well as swimming. All activities during the program will be under direct supervision at all times. I understand that the Missouri State Highway Patrol and Sunnyhill Incorporated will provide transportation for my son/daughter to and from the camp. If my son/daughter becomes ill or is injured during any activity, I understand that every reasonable effort will be made to contact myself or a member of my family. If I cannot be reached, I understand that emergency medical care will be sought by the advisor present. I understand that after medical care is sought, notification efforts will be continued. I agree to indemnify, defend, hold harmless and release the State of Missouri, Department of Public Safety, the Missouri State Highway Patrol, Sunnyhill Incorporated and any volunteers from any lawsuits, damages, claims, judgments, losses, liabilities or expenses arising out of the death, personal injury or property damage involving my son/daughter, which may be sustained while participating in activities with the Missouri State Highway Patrol Youth Academy Program. All of the terms above shall apply whether or not caused by the alleged negligence, either active or passive, or any acts or omissions of the Department of Public Safety or any of its officers, agents, employees, or volunteers. I have read, understand and comply with this RELEASE FROM LIABILITY. Signed: Date:
GRADUATION CEREMONY RSVP GRADUATION WILL BE HELD ON SATURDAY, JUNE 17 2017 12:00 P.M. (NOON) MARYLAND HEIGHTS COMMUNITY CENTER 2300 MCKELVEY MARYLAND HEIGHTS MO, 63043 FAMILY AND FRIENDS ARE WELCOME TO ATTEND! * A map to the facility will be sent with the acceptance package. NAME OF CADET: NUMBER OF GUESTS ATTENDING GRADUATION CEREMONY: