Citizen Police Academy Application for Enrollment

2. First Name*

3. Middle Name

4. Last Name*

5. Date of Birth*

   MM/DD/YYYY

7. Address*

9. City*

10. State*

11. Zip*

12. Home Phone*

14. Driver License # and State*

15. Email*

17. Employer / School Name

18. Business/Cell Phone

19. Shirt Size*
    -- Select One --XSSMLXLXXL

    (Men's Sizes)

21. How were you referred?*

22. Please list any medical conditions, allergies, or physical impediments we may need to know about:

24. Warning:
    During the eight week course, you will be exposed to different aspects of law enforcement to include, but not limited to; arrest control tactics, discharging firearms, and other aspects of law enforcement which may be hazardous to your health. As a participant, you are not required to participate in any of these physical demonstrations and those with medical conditions should consider not participating in the physically demanding parts of the course. As these demonstrations are non-mandatory for completion of this course, Draper City assumes no liability for those choosing to participate in any of these demonstrations.

    During the eight week course, you will be exposed to different aspects of law enforcement to include, but not limited to; arrest control tactics, discharging firearms, and other aspects of law enforcement which may be hazardous to your health. As a participant, you are not required to participate in any of these physical demonstrations and those with medical conditions should consider not participating in the physically demanding parts of the course. As these demonstrations are non-mandatory for completion of this course, Draper City assumes no liability for those choosing to participate in any of these demonstrations.

26. Please enter your initials, indicating that you have read and understand this information:*

28. Emergency Contact*

29. Relationship to you:*

30. Phone:*

32. Have you ever been arrested for a felony or are you currently on parole or probation?*
    -- Select One --NoYes

    (A background check will be conducted on each applicant. Any intentional misrepresentation will be grounds for immediate dismissal)

34. I hereby acknowledge that I have completed the above information fully and accurately. I understand and give my permission, with respect to the Draper City Police Department, to conduct a background investigation to determine my suitability for admission to this program.*

    Acknowledge by typing your full name above.

36. For more information, please call Sgt Scott Adams at (801) 576-6339.

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38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field