Please input all requested information. Completing this form online serves as ELECTRONIC SIGNATURE where indicated. Applications must be accompanied by a letter of recommendation to qualify for admittance.

In the event of an injury or should emergency care be required, I understand that every effort will be made to contact me. If I cannot be reached I hereby give my permission to LPSYLA staff to secure proper medical/surgical treatment for my child and authorize the staff from LPSYLA to sign for emergency medical/surgical treatment for my child. I do hereby release The Lansing Police Department, Lansing Fire Department and Lansing Parks and Recreation Department of any and all liabilities and such personal injuries as may result directly or indirectly from any activity conducted under the supervision and direction of aforementioned during participation in LPSYLA.

I authorize the videotaping and photograph of my child’s, image and/or voice for use in LPSYLA program materials, program marketing and social media. I understand and agree that these audio, video, film and/or print images may be edited, duplicated, distributed, reproduced, reformatted without payment of fees, in perpetuity.

As parent / guardian of participant of LPSYLA, I agree to the following:

As a student participant of LPSYLA, I agree to the following:

This agreement releases the City of Lansing, Lansing Police Department, its agents, employees and assigns, from all liability relating to injuries that may occur participation in the LPSYLA, June 17 -21 2019. By signing this agreement, I agree to hold affiliates of the LPSYLA entirely free from any liability, including financial responsibility for injuries incurred, regardless of whether injuries are caused by negligence. I also acknowledge the risks involved in participating in the LPSYLA. These include but are not limited to physical recreation, fieldtrips, and supervised interaction with other youth. I swear that my child is participating voluntarily, and that all risks have been made clear to me. Additionally, I do not have any conditions that will increase my likelihood of experiencing injuries while engaging in this activity. By signing below I forfeit all right to bring a suit against the City of Lansing, Lansing Police Department, its agents, employees and assigns for any reason. In return, I will receive application access to the LPSYLA. I will also make every effort to ensure my child obeys safety precautions as listed in writing and as explained verbally. I will ask for clarification when needed.

The Michigan Supreme Court wishes to photograph some of the visitors to the Court and its Learning Center in order to use the resulting photographs and images for brochures, advertisements, websites or other materials to promote the educational programs of the Court.

I hereby authorize the Michigan Supreme Court and its Learning Center to use my photograph or image for promotional purposes, and to use my name when the Court identifies persons in such a photo or image. I also authorize such use of the photographs or image and names of my minor child(ren)

I am at least eighteen years of age, and I acknowledge that this authorization is binding to my heirs and estate. On my behalf and on behalf of my children, I waive any compensation for the use described in this authorization.