Citizens Academy Application

PERSONAL

*First and Last Name:

*Date Of Birth:

*Current Address:

*City:

*State:

*Zip Code:

*Primary Phone #:

*Valid Ohio's Driver License #:

*Primary E-mail Address:

*Highest Level of Education:

*Have you ever been arrested or convicted of a crime?:

YesNo

If so, please provide details.:

*Have you ever been involved in a civil suit? :

YesNo

If so, please provide details.:

*Do you have any pending court cases?:

YesNo

If so, please provide details.:

OCCUPATION

*Current Employer or School Attending:

*Have you ever, or are you currently serving in the Armed Forces? :

YesNo

About the Program

What type of community groups, organizations or activities are you currently involved with or have you been previously?:

*How did you hear about this program?:

*Briefly explain why you wish to be accepted into the Sheriff’s Citizens Academy.:

How do you hope to help the community through this program?:

Other Franklin County Sheriff’s Office programs you’ve attended (RAD, CRASE)? :

What other Citizens Academy programs have you attended? :

Did you complete this program? Why/ why not?:

MEDICAL HISTORY

Please list any critical medical conditions of which we need to be aware: (ie: anaphylaxis allergies, heart conditions, seizure disorders, etc.):

List three (2) people to be contacted in case of an emergency:

Name:

Phone:

Please Read Waiver before signing Waiver & Release

Print Name:

Date:

Today

By submitting this form, I agree that all information provided is true, correct, and complete. The electronic signature on the form is authentic and signed by person named on the form.