Form Center

2. Student Information Section
4. First Name*
5. Last Name*
6. Date of Birth*
8. City*
9. Address*
10. State*
12. School Attending*
16. Parent / Guardian Information Section
18. First Name*
19. Last Name*
21. Address*
22. City*
23. State*
25. Phone Number*
26. Email Address*
27. Date of Birth*
31. Location:

    Day 1 (July 7, 2025): 

    • Drop off & pick Up: Rosenberg Police Dept. - 2120 4th St.

    Day 2 (July 8, 2025): 

    • Drop off & pick Up: Rosenberg Civic Center - 3825 State Highway 36 S.

    Day 3 (July 9, 2025):

    • Drop off & pick up - Fort Bend County Juvenile Probation (122 Golfview Dr. Richmond, TX)

    Day 4 (July 10, 2025): 

    • Drop off & pick up: Rosenberg Civic Center - 3825 State Highway 36 S. 

    Day 5 (July 11, 2025): 

    • Drop off & pick up: Rosenberg Civic Center - 3825 State Highway 36 S.

33. I am aware there may be different drop off and pick up locations during the week? *

    1. Yes
    2. No
37. Student Medical Information / Treatment Authorization Section
39. Student currently under a doctor’s care for any disability, chronic illnesses or taking any medication?*

    1. Yes
    2. No
41. If yes, explain:
43. MEDICAL RELEASE/ TREATMENT AUTHORIZATION*

    I, being the parent and /or legal guardian of the above named student, do hereby authorize the Rosenberg Police Department to act as an agent for the undersigned parent/guardian in the event of illness or injury occurring to my son/daughter while involved in activities related to my child’s attendance in the Rosenberg Police Teen Citizen Police Academy. I consent to the X-ray examination, anesthesia and/or medical or surgical diagnostic procedures or treatment considered necessary in the best judgement of the attending physician and performed by or under the supervision of a member of the medical staff of the hospital furnishing medical services. It is understood that in the event of a serious illness or injury, reasonable efforts to reach me will be attempted. This authorization shall remain effective as long as said student participates with the Rosenberg Police Teen Citizen Police Academy, unless revoked sooner in writing and delivered to the Police Department Community Relations Unit.
    

    By checking the "I agree" box below, you agree and acknowledge the above mentioned medical release / treatment authorization information and that 1) your signature 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.
45. Electronic Signature*
Leave This Blank:


49. Submit

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