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