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2. 2023 Summer Youth Program Application
4. Details
   • Every Thursday from June 22 through August 10
   • Noon to 4 p.m.
   • Cost: FREE!
   • Space is limited - not all applications may be accepted if capacity is reached
   • All sessions will begin at the Hopkins Police Department located at 1010 1st Street S
   • Transportation to and from the police department will need to be arranged by the parent/guardian
   • Upon successful completion, participants will receive a certificate and an invitation to a day long trip to Valley Fair
   • For more information contact Julia Ross at 952-548-6428
6. Student's First Name*
7. Student's Last Name*
9. Student's Age *

   (must be between 12-15)

10. Student's Cell Phone Number
11. Shirt Size*
    -- Select One --SMLXLXXL

    Please note these are adult sizes
13. Student's Street Address*
14. City*
16. Disabilities or Behavioral Concerns*
    If none, type "None."
17. Allergies or Medical Conditions*
    If none, type "None."
19. Parent/Guardian First Name*
20. Parent/Guardian Last Name*
22. Parent/Guardian Email Address*
23. Parent/Guardian Cell Phone Number*
25. Emergency Contact First Name*

    Other than parent/guardian listed above.

26. Emergency Contact Last Name*

    Other than parent/guardian listed above.

    
    

28. Emergency Contact Cell Phone Number*

    Other than phone number listed above.

    
    

30. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
32. Electronic Signature
Leave This Blank:


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

    This field is not part of the form submission.

36. Submit

* indicates a required field