MSPYLA Application (2014)

All applicants must be between the ages of 15-16 years of age at the start of the selected MSPYLA program (Saginaw, Flint, Detroit) to be admitted.

Select your current age:

I am interested in attending the MSPYLA from: (Please note that programs are separated by gender and location.) In order to qualify, your date of birth (DOB) must fall between the specified dates listed below.

Enter your date of birth (DOB) below. Please note that in order to successfully apply for a selected program, your date of birth MUST fall in the specified date range listed in the MSPYLA attendance choice field above.

Date of Birth (e.g., Month/Day/Year, xx/xx/xxxx)

Have you attended a Michigan State Police Youth Leadership Academy before? (e.g., American Legion, Kiwanis, MSPYLA)

If YES, when did you attend?

Start Date:
Ending Date:

First Name
Middle Initial
Last Name
Street Address (Include Apartment Number)
City
ZIP Code
Email Address
Telephone Number (Include Area Code)

Gender

Male
Female

School Name

Current Grade

Shirt Size (Adult Male Sizes)

Gym Shorts Size (Adult Male Sizes)

Shoe Size

(e.g., 4, 6 1/2, 9, etc.)

Bra Size (Females Only)

(e.g., 34B, 38C, etc.)

Please specify information for a parent or caregiver.

Title

First Name
Last Name
Relationship (e.g., Mother, Father, Grandparent, etc.)
Street Address (Include Apartment Number)
City
ZIP Code
Email Address
Telephone Number (Include Area Code)

Please list any food allergies.

Special Dietary Needs

Reference No. 1

Title

First Name
Last Name
Relationship (e.g., Teacher, Coach, Pastor, etc.)
Telephone Number (Include Area Code)

Reference No. 2

Title

First Name
Last Name
Relationship (e.g., Teacher, Coach, Pastor, etc.)
Telephone Number (Include Area Code)