Events Step 1 of 5 20% Name First Middle Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country School Attending and Grade LevelHave you attended an APD Hero Academy before? Yes No If yes, what year? Mother Name First Middle Last Daytime NumberOther NumberFathers Name First Middle Last Daytime NumberOther NumberEmergency Contact First Last Relationship to ChildEmergency Contact NumberEmergency Contact Other NumberJr. Cadet Shirt SizeYouth SmallYouth MediumYouth LargeYouth XLYouth XXLAdult SmallAdult MediumAdult LargeAdult XLAdult XXL Medical QuestionsIs your child currently taking any medications?YesNoIf yes, explain.Is your child currently under the care of a physician?YesNoIf yes, explain.Does your child have any allergies? (Medications, food, bee stings etc)YesNoIf yes, explain.Does your child have high blood pressure?YesNoIf yes, explain.Does your child suffer from any heart problems?YesNoIf yes, explain.Has your child ever suffered from exhaustion or heatstroke?YesNoIf yes, explain.Does your child have any emotional and or physical limitations that would hinder him/her from participating in any activities, police topics, or tours?YesNoIf yes, explain.Do you have health insurance?YesNoHealth Plan Policy #If you child should become ill and needs medical attention, what hospital should be used?Please indicate any special needs you child might have.***Keep in mind that all attempts will be made to contact a parent or emergency contact person before anything is done. However, should your child become hurt/injured and we are unable to contact a parent or emergency contact person, please sign here to consent to the rendering of medical treatment to your child.***Parent/ Guardian Signature Agreement ReleaseI hereby agree that the Albuquerque Police Department may use and/or record on film, tape or otherwise my child’s name, likeness, image and/or voice; my on-camera interview(s) and performance and any other material provided by me (e.g., biographical material, photographs, videotapes, film prints, artwork, contact information, etc.). I acknowledge and further agree that the Albuquerque Police Department Hero Police Academy shall exclusively own all rights (right to edit and/or alter) and the right to use said recordings to promote, publicize or market the Academy, at the complete and sole discretion of the Albuquerque Police Department. In addition, I also agree as follows: 1. I represent, warrant that I have the full right, power and authority to grant the rights granted herein. I am familiar with the nature of the Academy. 2. I have been informed and I fully understand that any advice given to me on or in connection with the Academy is for informational purposes only. Should I follow all or any part of such advice, I shall do so entirely at my own risk. 3. I understand and acknowledge that all travel in connection with my participation in the Academy will be at my sole responsibility, risk and expense. I acknowledge that I have carefully read the foregoing, that I understand it, that I was given the opportunity to ask questions about it and that I knowingly consent to all of the terms therein.* By checking I agree, Required Field Parent Guardian SignatureDate Agreement and Covenant Not To SueI, __________________________, parent or legal guardians of applicant hereby certify that there are no willful misrepresentations, omissions or falsifications in the answers to all questions. I understand that my omission or false statements on this application will be sufficient cause for rejection, enrollment, and dismissal from the Hero Police Academy. I fully understand that for my safety and the safety of others, I must follow all rules of the Hero Police Academy or I may be terminated. I also understand that APD may complete an investigation on any information provided and may ask for personal references. Sign Below.* By checking I agree, required field My child may participate in the following Physical Training Firearm Training Simulator Rappelling Snacks containing sugar Discipline Tug of War Rockwall Climbing Inflatable Obstacle Course I, ____________________________, parent or legal guardian of applicant asks for permission for my child to attend the Hero Police Academy, and I fully understand that the Albuquerque Police Dept. has no obligation to allow my child to attend and that permission to participate is solely voluntary by me and my said child. I, nor my child or our legal representative, heirs, assigned successors or personal representatives will bring any action whatsoever, upon any grounds whatsoever, against the City of Albuquerque, the Albuquerque Police Department, their agents or servants for any but are not limited to wrongful death, injury, (physical or emotional), or property damage that may occur as a result of attending a Hero Police Academy. I fully hold the City of Albuquerque, its Police Department, their agents and servants harmless from any such death, injury or property damage. Understanding these risks, it is still my decision to allow my child to participate in the Junior Police Academy. I assume full responsibility for such risks. Sign Below.* By checking I agree, required field This iframe contains the logic required to handle AJAX powered Gravity Forms. Patient's Name First Last Total Number of Immediate Family Members AttendingEmail (a consent form will be sent out prior to event)*Phone This iframe contains the logic required to handle AJAX powered Gravity Forms. Learn how you can get involved today.Make A DonationContact Us
