Operation R.I.S.K. Application

Date of Application*

Parent/Guardian Information

Parent/Guardian Full Name*

First Middle Last

Home Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Race*

Sex*

Work Phone

Home Phone

Cell Phone*

Email*

Participant Information

Participant's Full Name*

First Middle Last

Home Address

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Race*

Sex*

Work Phone

Home Phone

Cell Phone

School Attending*

List any hobbies, extracurricular activities, or sports that your child is involved in:*

Please list any type of medical conditions your child may have:

Please contact 545-3398 if you have any questions or concerns

May medical aid be rendered in case of an emergency?*

Please list any illnesses, ailment (physical or mental), medications your child may have:

Please contact 545-3398 if you have any questions or concerns

Information and Liability Data

Please explain in detail the issues you are having with your child:

What steps have you already taken to help your child?

Has your child ever been through a youth diversion program? If so, then which program?

Has your child ever been convicted of a misdemeanor or felony? If so, list the charges.

Is your child in a known criminal gang? If yes, which gang?

Please divulge any other type of information that we need to know about your child.

Waiver & Release of Liability, Assumption of Risk and Indemnity Agreement

The Columbia Police Department Operation R.I.S.K. program is an intense and hands on 24 hour youth diversion program. I understand that the purpose of this program is to deter youth from at risk or criminal behavior. I understand that my child will be held in the program for a full 24 hours and will experience an incarceration type of environment for the full 24 hours. My child will be dropped off or picked up at a designated site at 6pm, and will be delivered to a specified pick up site at 6pm the next day. I understand that Operation R.I.S.K. participants will undergo intense physical fitness type drills which will consist of but not limited to running, bending, jumping, reaching, and other type of physical fitness type drills. I agree that I have divulged everything to the best of my knowledge in reference to my child's physical, mental, and social condition, and any other detail that is pertinent to their safety and success in the program. I agree that the Columbia Police Department, partners, and agents will be held blameless and not at fault by the parent or guardian, who has voluntarily and freely enrolled their child into this program. I agree that the Columbia Police Department, partners, and agents, will not be held responsible for any injuries minor or severe, up to and including death. I understand that my child will be in the supervision of sworn and certified Columbia Police Department officers and staff. By agreeing to this form, I attest and agree that I am the legal guardian of the participant.

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Parent/Guardian Information

Participant Information

Information and Liability Data

Waiver & Release of Liability, Assumption of Risk and Indemnity Agreement

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