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Event Timing: July 11 - July 22, 2022
Event Address: 4575 Washington Florissant, MO 63033
Contact Sgt. Kim Berry at kberry@florissantmo.com

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ZIP*
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Second portion of ZIP Code is optional.
Applicant's Cell Phone Number:*
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Date of Birth:*
 Date of Birth:
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Gender:*
 
T-Shirt size:*
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Parent/Guardian Cell Phone:*
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Parent/Guardian Home Phone:*
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The Florissant Police Department Future Leader Academy will include various types of physical activity.
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If the applicant must bring medication with them, it must be prescribed to them, in the original prescription bottle and packaging. Any medication that is to be taken during the Future Leaders Academy, a physicians release form will need to be obtained before the attending.
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Emergency Contact Cell Phone Number:*
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Emergency Contact Employer Phone Number:*
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To participate in the Florissant Police Department Future Leaders Academy, I hereby release all liability to the City of Florissant, it's elected officials, the Florissant Police Department and it's employees, both collectively and individually of any illness, injury-physical or emotional that may result in the participation in the Florissant Police Department Future Leaders Academy.
Check box to agree. 
Check box to agree after reading:*
The undersigned, being of legal age and the parent/guardian of the applicant, in consideration of said minor being allowed to participate in the Florissant Police Department Future Leader Academy, does herby release, acquit and discharge the City of Florissant and all persons, firms or corporation's connected, associated with, or employed by the City of Florissant from any and all liability whatsoever arising out of or in action for injuries or losses of every nature which the undersigned has or may have as the parents or heir of said minor child. I freely and voluntarily sign this release and indemnification agreement.
I hereby grant permission for the Florissant Police Department to provide transportation to and from locations of this program.
I hereby give my permission to the Floirssant Police Department to secure medical assistance for my child in the event i cannot be reached in an emergency.
I understand every effort will be made to ensure the safety of the applicant.
I understand that the Florissant Police Department is an equal opportunity employer and that all qualified applicants will be considered without regard to race, color, religion, sex, age, national origin, ancestry, sexual orientation or disability.
I understand that the City of Florissant reserves the right to take photographs and video of the applicant participating in this program. Photos and video may be used in print and or electronic publicity without any obligation to provide compensation to those photographed. I understand that if i do not consent to the applicant being photographed, I must inform the program coordinator before the start of the program.
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