Name: _______________________________________________________________

            Last                                         First                                         Middle Initial

Address: _____________________________________________________________

                Street/Apt#                                         City                         State         Zip

Phone: Home:_____________ Work:____________ Email:_________________________

Social Security Number:_______________________ Date of Birth:________________

Drivers License: State:_____________ Number:_____________ Expires:____________

Class:_______ Currently valid?     Yes     No

Have you ever been convicted of a felony?     Yes     No

Employer:_____________________________________________________________

Address: _____________________________________________________________                                    Street/Apt#                                     City                             State         Zip

Duties Performed:_______________________________________________________

_____________________________________________________________________

What do you expect to get out of the academy? _________________________________

______________________________________________________________________

CAREFULLY READ AND SIGN THE FOLLOWING

I am applying to be a participant in the City of Tempe Citizen Police Academy. I acknowledge

that my participation will include not only classroom lectures, but hands-on exercises as well.

In consideration of my being permitted to attend the Citizen Police Academy, I agree to assume all

risks associated with my participation, and release and hold harmless the City, Its officers, agents

and employees from and against any and all claims, damages, liabilities, costs and expenses,

including attorney's fees, arising out of my participation, including without limitation any personal

or bodily injuries or property damage that I may incur as a result of the actions of myself or other

persons.

I agree to abide by all rules and instructions given by th City, its officers, agents or employees

with respect to my participation.

I warrant that I am of legal age and fully understand the foregoing terms.

____________________________________________________________________________

Signature                                                                                            Date

____________________________________________________________________________

If the participant is under 18 years of age, the following needs to be

executed by the parent or guardian.

 For further information call the Citizen's Police Academy Coordinator at 480-350-8856

RETURN THIS APPLICATION PROMPTLY TO:

Citizen Police Academy

Tempe Police Department

120 E. Fifth Street