Citizen's Academy Application

APPLICATION FOR

PAGE POLICE DEPARTMENT CITIZEN'S POLICE ACADEMY

Page Police Department

Tim Lange, Chief of Police
- Applicant must be at least 18 years old
- Applicant must have no prior felony arrests or convictions.
- Applicant must have no misdemeanor arrests or convictions within the last 12 months.
Last
First
Middle
Maiden name or alias
Gender
Social Security Number
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:
Street - Apt.#
City
State
Zip Code
Previous Address (list previous addresses; 5 years)
From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous Address (list previous addresses; 5 years)
From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Additional Addresses - If Necessary (Only last 5 years)
Other states you have lived in
Home Phone
Format: (000) 000-0000.
Office Phone
Format: (000) 000-0000.
Mobile Phone
Format: (000) 000-0000.
Email address
example@example.com
Driver License State and Number
Class
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is this license valid:
Have you ever been arrested or convicted of any felony?
If YES explain where when and disposition
Place of Employment
Street
City
State
Zip Code
Duties Performed
I certify that all statements made on this application are true and complete. I authorize any individual, company, organization or institution to release any and all available information relating to me or concerning statements made by me on this application, and I do hereby release all parties and individuals connected therewith from all liabilities for any damages whatsoever incurred in furnishing such information. I agree and understand that any deliberate misstatement or omission of material facts may disqualify me from attending the Citizen's Academy Training. My signature below acknowledges my understanding and agreement with material provided.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
WAIVER AND RELEASE

I, First Name Last Name in return for the opportunity to participate in the CITIZEN'S ACADEMY, hereby release and acquit the Page Police Department and the City of Page, and any of its servants, employees, agents or volunteers from any and all liability claims, causes of action, claims or demands, including but not limited to a claim for death, which I may hereafter have because of my injury, death or damage to person or property while participating in activities of the CITIZEN'S ACADEMY, such activities, some of which may be inherently dangerous, may include but are not limited to search and rescue, field trips, including visits to detention and correctional facilities, traffic enforcement, DUI enforcement, investigation of crimes and introduction to and use of tools used by law enforcement.
I understand that participating in the CITIZEN'S ACADEMY activities contains danger and risk of injury or death, and that I am under no obligation to participate in any particular activity. By participating in the CITIZEN'S ACADEMY and in a particular activity, I understand that I am voluntarily choosing to accept any and all risks which may arise from my participation in the CITIZEN'S ACADEMY and the particular activities. This waiver, release and discharge includes all claims arising from and by reason of any and all known and unknown, foreseen or unforeseen, bodily and personal injures or death, or damage to property which may be sustained by me or any and all other persons, associations or corporations, whether named or not, arising out of my participation in the CITIZEN'S ACADEMY. I grant this waiver and release voluntarily. The Undersigned hereby releases, waives, discharges and covenants not to sue Page Police Department and the City of Page and any of its servants, employees, agents or volunteers for all loss or damage on account of injury to the person or property or resulting in death of the undersigned, whether caused by the negligence of releasees or otherwise, while the undersigned is participating in the CITIZEN'S ACADEMY. The undersigned expressly acknowledges that the activities of the event may be very dangerous and involve the risk of serious injury and/or death and/or property damage. The undersigned expressly acknowledges that injuries received may be compounded or increased by negligent rescue operations or procedures of the releasees.

PLEASE READ CAREFULLY BEFORE SIGNING

I,Your Name have read this Release and Waiver and understand its terms,
acknowledge the danger and risk associated with these activities, and accept the terms of the Release and Waiver and voluntarily assume the risk of participating. (I understand that typing my name constitutes a legal signature.
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