Junior Police Academy Data Form

Personal Information

Name:*

Address:*

City:*

State:*

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Zip:*

Contact Ph:*

Email:*

Date of Birth:*

SSN:*

School Attending:*

Grade:

Parent/Guardian Information (If Explorer is a minor)

Name of Parent/Guardian:

Email:

Home Ph:

Work Ph:

Certification/Authorization

I hereby certify that the information contained in this application is true and complete to the best of my knowledge. You are hereby authorized to make any investigation of my personal history deemed necessary in consideration for my acceptance into the Muscatine Police Explorer Program.

I agree with the above statement.*

Yes

No

Explorer Signature:___________________________________________

Parent/Guardian:_____________________________________________

Date:______________________________________________________