CMPD Youth Envision Academy

Summer Academy Application

Application Type

Name of Participant

LAST Name

FIRST Name

MIDDLE Name

Name You Prefer to be Called

Date of Birth

Race of Participant

Home Phone Number

Contact Cell Phone #

Contact Email Address

Unisex Shirt Size

Are you currently enrolled in school?

What is the name of the school that you attend?

Current Grade Level

What is your anticipated graduation date?

Are you planning to apply to a college, university or technical school after graduation?

What are your plans after graduation?

Do you have Summer School?

If you are attending Summer School, please provide dates:

START date

END date

Please list other dates unavailable for this Youth Envision Academy

Are you currently working?

Do you have transportation?

Is your residence located on or near a bus / rail line?

Name of agency and person who recruited you to the Youth Envision Academy

Briefly state why you want to participate in the Youth Envision Academy

Briefly describe yourself

Please list your career interests

Parent / Guardian Information

Parent / Guardian Name

LAST Name

FIRST Name

Middle Name

Relationship to you

Home Phone Number

Cell Phone Number

Work Phone Number

Contact Email Address

Are you related to a CMPD Employee?

Name of related CMPD Employee

Parent / Guardian Consent

I do hereby consent and agree that Youth Envision Academy, and any of their affiliates, has permission to take photographs and/or audio of my child and/or my child’s property to use for Youth Envision Academy educational, promotional, and/or marketing materials. I further consent that their name and identity may be revealed therein or by descriptive text or commentary. Neither individual addresses nor telephone numbers will be published within these materials.

I do hereby give the Youth Envision Academy the right to exhibit any such works publicly or privately, including posting on the CMPD Website.

I waive any rights, claims, or interest I may have to control the use of my child’s identity or likeness in the photographs, video or audio and agree that any uses described herein may be made without compensation or additional consideration to me or my child.
I represent that I have read and understand the foregoing statement and I am competent to execute this agreement.

Parent / Guardian Signature

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Please submit this application to your Youth Envision Academy liaison/agency representative along with a letter of recommendation from your HS School Counselor, Teacher, SRO or Program Coordinator.

Upload Letter of Recommendation from your High School Counselor, Teacher, SRO or Program Coordinator

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