Citizen Police Academy Application

Citizen Police Academy Application
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Where did you hear about the CPA?*

FacebookSafety FairNews releaseWord of mouthFlyer (please explain where you saw it below)
If you saw an advertising flyer for the CPA, please tell us where you saw it.
Work Information

If you are retired or unemployed, list that in the occupation field and leave the other fields blank.
Occupation*
Business Name
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone
Please enter a valid phone number.
Business Email
example@example.com
Reference Information
One Character Reference*
Provide their first and last name.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Years Acquainted*
Please read carefully before signing:
- Due to the nature of the course curriculum, the Raytown Police Department will be conducting background checks on all participants, including but not limited to a check of the criminal justice information systems. I hereby authorize the Raytown Police Department to collect personal information concerning myself. I acknowledge this information is to be used for enrollment purposes only and that the Raytown Police Department reserves the right of sole discretion in the selection of applicants.
- I hereby declare that the foregoing information is true, accurate, and complete to the best of my knowledge. I understand that a false statement can disqualify me from participation in the Raytown Police Department Citizens Academy. I agree that I will not disclose any confidential information that I become aware of through participation in the Citizens Academy.
Signature*

Clear
In addition to this application, you must complete and return the Release Agreement, found here (it will download) and the Ride Along form that can be found here.

The application and both documents must be completed by the registration deadline of September 13th, 2023.

If you cannot upload the documents here, they may be returned by email to RPDVolunteercorp@gmail.com.
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Citizen Police Academy Application

Personal Information

Work Information

Reference Information

Please read carefully before signing: