signature x i understand that any misrepresentation of ... police academy application 18.pdfhigh...
TRANSCRIPT
Home Address
Email Date of Birth Height
Name of High School
Race
Sex Weight
Shirt Size
Expires On
Location Trumbull Campus (Semester)
Phone: 330-675-7666
Location Kent Campus (Semester)
Phone: 330-672-0325Police Academy Application
Place of Birth (city,state and county)Lived in OH more than 5 yrs?
Your training requires you to participate in a moderately rigorous form of unarmed self-defense and physical conditioning. Do you have any type of physical disability or limitation that would prevent you from fully participating in these forms of exertion?
CONFIDENTIAL QUESTIONNAIRE
County
Marital Status
Driver License#
US Citizen?
Ever charged with an OVI/DUI? If YES, how many?
Driver License Info
Any points on your license currently ?
# of Points
Education
Highest grade completed
Year Graduated
While attending high school or college, did you, or, do you currently have an Individualized Education Plan (IEP) or a Sec. 504 accommodation?
Degree
Major
Name of College
Year Graduate
I understand that any misrepresentation of facts on this form could be cause for refusal of admission, cancellation of admission, or suspension from the Academy if discovered.
Signature X
How did you hear about us ?Were you referred to the Police Academy?
Have you ever been arrested or convicted of a misdemeanor or felony ? If YES, please explain below when, what the charge was, and if it was Domestic Violence related. (PLEASE NOTE: This includes anything you may have had EXPUNGED from your record).
Shift
Veteran Information
Employment
If a Veteran, what was your discharge date? Branch of Service GI Bill Eligible?
Current Employer Job Title
Address
Hours per Week
City State
Last Name First Name Middle Name Cell or Home Phone #
Zip
Social Security Number
State of Issue
OVI/DUI Details
Arrest Record
Physical Fitness
DateRevised 09/01/17 KSUPA
EMERGENCY NOTIFICATION FORM It is the practice of the Police Academy to provide the maximum amount of service and
efficiency in its operation. In keeping with this practice, every cadet is asked to share information with the school so that if an injury or illness should occur, the best interest of the student can be served by having information available that can help us help you.
Last Name First Name Middle Name
StateHome Address City Zip
WHO SHOULD BE NOTIFIED IF AN ACCIDENT OR ILLNESS SHOULD OCCUR?
Full Name
Full Name
Cell or Home Phone # Relationship
Cell or Home Phone # Relationship
RelationshipFull Name Cell or Home Phone #
Date of Birth
Name of Family Doctor Phone Number
Hospital Preference
Are you Allergic to Any Medications?
Cadet Information
Doctor Information
Additional Emergency Information
Cell or Home Phone #
Character References All applicants are required to provide the academy with complete names and addresses of at least three character references.
Close friends and relatives are not acceptable for this purpose.
Acceptable References: Employer, Former Employer, Boss, Priest, Minister, Rabbi, Attorney, Doctor, Teacher, High School Guidance Counselor, Principal, Professor, Someone in Law Enforcement, Neighbor, etc.
PLEASE COMPLETE THE FOLLOWING
REFERENCE #1
City
Full Name Address
State Zip Code
EmailPhone Number
City
Full Name Address
State Zip Code
EmailPhone Number
City
Full Name Address
State Zip Code
EmailPhone Number
Middle Name
Home Address City State
Last Name First Name
Zip
For how long and in what capacity do you know this person ?
For how long and in what capacity do you know this person ?
For how long and in what capacity do you know this person ?
REFERENCE #2
REFERENCE #3
Cell or Home Phone #
Cadet Information
REQUEST FOR TRANSCRIPT
Please complete this release form and turn it in to your High School or College. They will fax or mail a copy of your transcript to us. Please be sure to sign the bottom of this form.
HIGH SCHOOL GED CERTIFICATE COLLEGE
Police Academy (Kent Campus) 189 Schwartz Center Kent, Ohio 44242-0001 Fax: 330-672-0070 Phone: 330-672-0325
Police Academy (Trumbull Campus) 4314 Mahoning Ave. N.W. Warren, Ohio 44483-1998 Fax: 330-675-7676 Phone: 330-675-7666
In compliance with the Family Education Rights and Privacy Act of 1974, I hereby request and authorize that a copy of my High School Transcript, GED Certificate, or College Credits be sent to:
HIGH SCHOOL INFORMATION
Your legal name while in attendance Year Graduated:
Middle Name
Home Address City State
Last Name First Name
Zip
Date of birth
High School Name
Address City State Zip
COLLEGE INFORMATION
Your legal name while in attendance Year Graduated
College Name
Address City State Zip
GED INFORMATION
Your legal name while in attendance Year Graduated
School Name
Address City State Zip
Applicant's Signature X Date
Cell or Home Phone #
Cadet Information
Last 4 SSN XXX-XX-
BUCKLEY AMENDMENT FORM Family Educational Rights and Privacy Act of 1974
P.L. 93-380, SECTION 438
The Family Educational Rights and Privacy Act of 1974 (FERPA), prohibits an institution from releasing the school records or any other information about a student to any third party without the written consent of the student. In compliance with this law, Kent State University is providing this form to indicate your desire concerning release of information to third parties.
I, , permission to
release my school records and other similar information to: The Peace Officer Training Commission,
Law Enforcement Agencies, Sponsoring/Funding Agency, Commissioning Agency, Prospective
Employer(s), or third parties.
(do grant) (do not grant)(Name of Student)
Cadet's Signature X Date
Witness Signature X Date