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Antioch Police Youth Academy Application
Complete EVERY question unless stated as “optional” , otherwise, your application may be returned as incomplete
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* Indicates required question
Email Address
*
Your answer
First Name
*
Your answer
Last Name
*
Your answer
Address
*
Your answer
City
*
Your answer
State
*
Choose
CA
Zip Code
*
Your answer
Telephone
*
Your answer
Mobile Phone (Optional/ If Available)
Your answer
Gender
*
Female
Male
Date of Birth
*
MM
/
DD
/
YYYY
Any special considerations?
*
Your answer
Driver's License # or California ID #
Your answer
Name of Employer / School
*
Your answer
Grade Level
*
Choose
Kindergaren
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College Freshman
College Sophmore
College Junior
College Senior
How long have you lived in Antioch?
Your answer
Have you ever been suspended or expelled from any school?
*
Yes
No
If “YES,” please explain and include date(s) of occurrence.
Your answer
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