Citizen Police Academy Application for Enrollment

Required fields are marked with asterisks (*)

Citizen Police Academy Application for Enrollment

First Name

Middle Name

Last Name

Date of Birth

Address

City

Zip Code

Phone Number- Primary

Enter Your Driver License # and State

Please upload a photo of your driver's license.

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Allowed extensions jpg, jpeg, png

Employer / School Name

Business/Cell Phone

How were you referred?

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

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.

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

Emergency Contact

Relationship to you:

Phone Number- Emergency Contact

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.

I authorize a release of my Utah Criminal History record, or any part thereof, by and to any duly authorized agent of this agency to accompany my employment, volunteer, licensing, permit application, or other expressed purpose approved by me today. Any information discovered may be used to consider my suitability for the purpose of my application.

Notice:
I understand these results are not verified by fingerprints and are only valid on the date printed on this record. If I wish to challenge the completeness or accuracy of this record, I must submit a completed Application to Challenge Criminal History Records with fingerprints directly to the Bureau of Criminal Indentification (BCI) where I may be subject to additional fees (R722-900-6).

I understand this waiver may be kept on file at this agency for a period of at least three years and is subject to review by BCI auditors, whether or not I choose to release my record to this agency today. I agree to indemnify and hold harmless BCI, this agency, elected officials, officers, employees, agents, and volunteers associated with this application process from and against all claims, damages, losses, and expenses, including reasonable attorney's fees arising out of or by reason of complying with this request.

A photocopy or electronic copy of this waiver is a valid representation of my original signature and is considered legal and binding just as the original writing of my signature.

For more information, please call (801) 576-6352.

Please type your FULL NAME to acknowledge and sign this form.

For Office Use Only:

Identification Verified:___________ Date:____________________

Criminal History Completed By: _________ Date:______________________