Citizens Police Academy

2. First Name *
3. Last Name*
4. Middle initial*
6. Email Address*
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Alternate Phone Number
17. Business Address
19. Business City
20. Business State
21. Business Zip Code
23. Business Phone Number
25. Emergency Contact First Name*
26. Emergency Contact Last Name*
28. Emergency Contact Phone Number*
30. Have you ever been convicted of a criminal offense?*

    1. Yes

    1. No
32. If yes to above, please explain.
34. Shirt Size*
    -- Select One --Male SmallMale MediumMale LargeMale XLMale XXLFemale SmallFemale MediumFemale LargeFemale XLFemale XXL
36. Background Check Waiver

    By agreeing below you are consenting to a background and criminal history check to be conducted by an Investigator/Officer with the Union Township Police Department. The sole reason for this check is for the voluntary participation and admission into the Union Township Police Department's Citizen's Police Academy.  Union Township reserves the right to deny participation to any subject refusing to submit to the background check, or who submits and is found to have been convicted of or indicted for a criminal offense.

38. Release of Liability

    I and my heirs, in consideration of my participation in the Union Township Police Citizen Police Academy, do hereby release and hold harmless Union Township, its officers, employees and agents and any other people officially connected with this event, from any and all liability for damage to or loss of personal property, sickness or injury from whatever source, legal entanglements, imprisonment, death, or loss of money, which might occur while participating in this event or as a result of participating in this event. Specifically, I release said persons from any liability or responsibility for my physical condition and for the presence or actions of any other participants. I am aware of the risks of participation which include, but are not limited to; the possibility of personal injury and/or fatigue, exposure to graphic photographs, exposure to physical activity or contact, exposure to course, profane or abusive language, exposure to firearms, blunt impact weapons and electronic devices, exposure to disturbing scenes or circumstances that police officers encounter in the performance of their duties. I hereby state that I am in sufficient physical condition to accept a rigorous level of physical activity. I understand that participation in this program is strictly voluntary, and I freely choose to participate. I understand that Union Township does not provide medical or liability insurance coverage for me. I verify that I will be responsible for any medical or liability costs I incur as a result of my participation.

40. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. 4) By electronically signing this form, you are agreeing to both the Background Check Waiver and Release of Liability.

    1. I agree.
42. Electronic Signature*
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field