Citizens Academy Application Form

Citizens Academy Application Form

Applicants must be 18 years of age or older to attend the Citizens Academy. Applicants must live, work, or frequent the University Circle neighborhood. No prior felony convictions or criminal history.
Today's Date*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Driver's License #*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Email Address*
example@example.com
Occupation*
Company Name*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Business Email Address*
example@example.com
In case of emergency please notify:
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship:*
Please answer (yes or no) to the following questions and provide explanations where needed
Do you authorize the University Circle Police Department to do a background check?*

YesNo
Have you ever been arrested for a crime other than a traffic offense?*

YesNo
If yes, please explain with dates and disposition:
Do you have a valid driver's license?*

YesNo
Are you 18 years of age or older?*

YesNo
Do you have any special needs that require accommodation for you to participate in the Citizens Police Academy program?*

YesNo
If yes, please explain below:
Do you have any allergies we should be aware of?*

YesNo
If yes, please list below:
How did you hear about the academy?*
What do you know about University Circle Police Department?*
Have you ever applied for or attended a Citizens Police Academy?*

YesNo
If yes, please list where and when:
I hereby certify that there are no falsifications, omissions, or misrepresentations in the foregoing statements and answers to questions. I understand that any omission or false statement on the application shall be sufficient cause for rejection for enrollment or dismissal from the University Circle Police Department Citizens Academy. I also grant permission for the University Circle Police Department to verify the above information contained on this application and check for prior criminal history.
Signature of Applicant*
Date*

MonthDayYear
Date
The University Circle Police Department regularly uses social media to highlight our activities, do you consent to having your Participant's photograph used in our promotional posts?*

YesNo
Should be Empty:

Citizens Academy Application Form

In case of emergency please notify:

Please answer (yes or no) to the following questions and provide explanations where needed