Lansing, MI

City of Lansing Public Safety Youth Leadership Academy Application

Steps

1. Application This section is complete This section is incomplete
2. Release Statements and Signatures This section is complete This section is incomplete
3. Waiver of Liability This section is complete This section is incomplete
4. Michigan Supreme Court Learning Center - Photograph / Image Release This section is complete This section is incomplete

Application

City of Lansing Public Safety Youth Leadership Academy
Participant Application Form
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.
Applicant Information
Full Name of Applicant*
Date of Birth*
Date of Birth
Address*
City, State, ZIP Code*
Email Address*
Letter of Recommendation
Upload your letter of recommendation here.
Academic Information
School*
Grade Level*
Favorite Subjects*
Uniform Measurements
Shirt Size*
Pants Size*
Parent / Legal Guardian Information
Full Name*
Relation to Student*
Work Phone Number*
Home or Mobile Phone Number*
Medical Information
List of illnesses, allergies, related medications*
Health Insurance Provider and ID Number*
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Release Statements and Signatures

Medical Release Statement
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 LPS YLA staff to secure proper medical/surgical treatment for my child and authorize the staff from LPS YLA 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 LPS YLA.
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 LPS YLA staff to secure proper medical/surgical treatment for my child and authorize the staff from LPS YLA 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 LPS YLA.
Parent / Guardian Name*
Date Signed*
Date Signed
***This will be considered an ELECTRONIC SIGNATURE***
Photo Release
I authorize the videotaping and photograph of my child’s, image and/or voice for use in LPS YLA 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.
Parent / Guardian Name*
Date Signed*
Date Signed
***This will be considered an ELECTRONIC SIGNATURE***
Parent / Guardian Commitment
As parent / guardian of participant of LPS YLA, I agree to the following:
- Ensuring that the program participant abides by the guidelines and rules of LPS YLA.
- Participating in or arranging designee to participate in Parent Student Interaction Activity on Day 5.
- Maintaining high expectations for program participants.
- Staying in contact with LPS YLA Staff.
- Cleaning of LPS YLA uniform attire as necessary.
***Adherence to the aforementioned obligations are required conditions of admittance into LPS YLA.
Parent Name*
Date Signed*
Date Signed
***This will be considered an ELECTRONIC SIGNATURE***
Participant Commitment
As a student participant of LPS YLA, I agree to the following:
- Attend and actively participate in 100% of all program activities.
- Abide by the guidelines and rules of LPS YLA.
- Adhere to program dress code: Wearing issued LPS YLA uniform attire.
- Make good decisions and be held accountable for my choices/actions and maintain high learning expectations for oneself.
***Failure to adhere to the aforementioned obligations may result in loss of LPS YLA privileges and can lead to removal from the program.
Student Name*
Date Signed*
Date Signed
***This will be considered an ELECTRONIC SIGNATURE***
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Waiver of Liability

Waiver of Liability
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 18 -22 2018. 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.
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 18 -22 2018. 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.
Full Name*
I fully understand and agree to the above terms.
Date Signed*
Date Signed
***This will be considered an ELECTRONIC SIGNATURE***
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Michigan Supreme Court Learning Center - Photograph / Image Release

Michigan Supreme Court Learning Center
Michigan Hall of Justice - P.O. Box 30205 - Lansing, MI 48909
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)
Full name(s)
Enter child(ren) name(s)
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.
Parent / Legal Guardian Name*
Date Signed*
Date Signed
***This will be considered an ELECTRONIC SIGNATURE***
Address*
City, State, ZIP Code*
Phone Number*

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1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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City of Lansing Public Safety Youth Leadership Academy Application

Steps

Application

City of Lansing Public Safety Youth Leadership Academy

Participant Application Form

Applicant Information

Academic Information

Uniform Measurements

Parent / Legal Guardian Information

Medical Information

Release Statements and Signatures

Medical Release Statement

Photo Release

Parent / Guardian Commitment

***Adherence to the aforementioned obligations are required conditions of admittance into LPS YLA.

Participant Commitment

***Failure to adhere to the aforementioned obligations may result in loss of LPS YLA privileges and can lead to removal from the program.

Waiver of Liability

Waiver of Liability

Michigan Supreme Court Learning Center - Photograph / Image Release

Michigan Supreme Court Learning Center

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