CLATSOP COUNTY CITIZEN POLICE ACADEMY

CLATSOP COUNTY CITIZEN POLICE ACADEMY
APPLICATION FOR ADMISSION & WAIVER
Last
First
Middle
Maiden/other
Date of Birth

MonthDayYear
Date
Sex
Social Security Number
Address
Home/Cell Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Email Address
example@example.com
Drivers License Number
State
Occupation
Employer
Have you ever been arrested for a crime other than traffic offenses?
If yes please explain
Emergency Contact Name
Phone
Format: (000) 000-0000.
How did you hear about the Citizens Academy?
What do you expect to gain from attending this Academy?
What experience have you had with police? Do you consider these experiences to be positive or negative?
RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT FOR CLATSOP COUNTY CITIZEN POLICE ACADEMY

The undersigned, in consideration for the privilege of being a participant in the Citizen Police Academy of the Cities of Seaside, Gearhart, Cannon Beach, Warrenton, Astoria, County of Clatsop, and the Oregon State Police and recognizing that such activity involves certain inherent risks and dangers, does hereby agree to assume the risks attendant to all activities associated with participation in the Citizen Police Academy of the Cities of Seaside, Gearhart, Cannon Beach, Warrenton, Astoria, County of Clatsop, and the Oregon State Police.

The undersigned for him/herself, legal representatives, heirs and assigns does hereby release, waive and discharge the Cities of Seaside, Gearhart, Cannon Beach, Warrenton, Astoria, County of Clatsop, and the Oregon State Police, its officers, agents and employees for any liability for any loss or damage or any claim or damages resulting from my participation in the Citizen Police Academy of the Cities of Seaside, Gearhart, Cannon Beach, Warrenton, Astoria, County of Clatsop, and the Oregon State Police on account of any injury to me or my property, whether caused by negligence of the Cities of Seaside, Gearhart, Cannon Beach, Warrenton, Astoria, County of Clatsop, and the Oregon State Police its officers, agents and employees, or otherwise, while participating in the Citizen Police Academy of the Cities of Seaside, Gearhart, Cannon Beach, Warrenton, Astoria, County of Clatsop, and the Oregon State Police. The undersigned hereby agrees to indemnify, defend and hold harmless the Cities of Seaside, Gearhart, Cannon Beach, Warrenton, Astoria and County of Clatsop, its officers, agents and employees from any and all claims, losses, damages, causes of action, and liability, including all expense of litigation for injury to any person or loss of property arising out of my participation in the Citizen Police Academy of the Cities of Seaside, Gearhart, Cannon Beach, Warrenton, Astoria, County of Clatsop, and the Oregon State Police.
Signature
Print Name
AUTHORITY TO CONDUCT BACKGROUND INVESTIGATION
As an applicant to participate in the Clatsop County Citizen Police Academy, I hereby authorize the City of Cannon Beach Police Department to conduct a criminal history background investigation. I understand that such background investigation is being conducted due to the content of the classes given at the Academy. I understand that available police and criminal records will be checked and that the information will be used in the determining my eligibility for the Citizen Police Academy. All information will remain confidential as provided by Oregon and Federal Statutes.
Signature
Date

MonthDayYear
Date
Print Name
STUDENT AGREEMENT
I understand that space is limited, allowing only thirty students to participate in the Citizen Police Academy. Therefore, I agree to attend at least 7 of the 9 scheduled sessions. Additionally, I agree to arrive promptly and to complete and return the evaluation form provided for each session.
Signature
Date

MonthDayYear
Date
Print Name
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CLATSOP COUNTY CITIZEN POLICE ACADEMY

APPLICATION FOR ADMISSION & WAIVER

AUTHORITY TO CONDUCT BACKGROUND INVESTIGATION

STUDENT AGREEMENT