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2. Name*
3. Middle Name
4. Last Name*
6. Driver License #
7. State
8. Gender*

   1. Male
   2. Female
9. Date of Birth*
   Date of Birth
13. Address*
14. City*
15. Zip Code*
17. Cell Phone Number*
18. Email Address*
20. School
21. Grade
22. Graduation Year
24. Do you participate in extracurricular acitivities?*
    -- Select One --YesNo
25. Extra Curricular Activities*

    Please add the days of the week that you participate in these activities.

26. Will the extracurricular activities keep you from attending Tuesday meetings?*
    -- Select One --YesNo
27. T-Shirt Size*
    -- Select One --X-SmallSmallMediumLargeX-Large
29. Have you previously been part of Explorers or Public Safety Cadets?*

    1. Public Safety Cadets
    2. Explorers
    3. None
30. If so, where?*
32. PARENT(S)/GUARDIAN(S)
34. Guardian*
    -- Select One --MotherFatherGrandmotherGrandfatherAuntUncleCousinOther
35. First Name*
36. Last Name*
37. Cell Phone No.*
39. Address if different from applicant
40. City
42. Guardian #2
    -- Select One --MotherFatherGrandmotherGrandfatherAuntUncleCousinOther
43. First Name
44. Last Name
45. Cell Phone No.
47. Address, If Different from Applicant
48. City
50. EMERGENCY CONTACT
52. First Name
53. Last Name
54. Phone Number

58. I hereby grant to the City of Palestine, Palestine Police Department, and Youth Corps Unit $1871 the right to use any photographic image of myself.  I understand that the City of Palestine, Palestine Police Department, and the Youth Corps Post #1871 will utilize these images for the non-profit, governmental purpose of communicating public information regarding city and department services, programs, and facilities.  I also understand that I release any claim, right, or title to said photographs or images.

60. 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.
62. Applicant Electronic Signature*
63. Today's Date*
    Today's Date
65. Parent Electronic Signature*
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit

* indicates a required field