2. Contact Information
4. First Name*
5. Middle Initial
6. Last Name*
8. Address1*
10. Address2
    if applicable
12. City*
13. State*
14. Zip*
16. Phone Number*
17. Email Address
19. Age*
20. Date of Birth*
21. Ohio Driver's License Number*
22. SSN
24. Place of Employment
25. Occupation
27. Volunteer Information
29. List Interests Here*
31. Please List Related Skills or Work Experience
    prior law enforcement experience, work in criminal justice field, family members in criminal justice field...
35. Criminal History
    Applicants must be at least 18 years of age. All CPA applicants will be subject to a background check. The following is a partial list of offenses which may disqualify you from participation in this program: any felony offense, offenses involving weapons, assault, drug or narcotics offenses.
37. Arrest*

    Have you ever been arrested?

    1. Yes
    2. No
38. If Arrested Felony or Misdemeanor

    1. Misdemeanor
    2. Felony
39. Conviction*

    Have you ever been convicted of a criminal offense?

    1. Yes
    2. No
40. Sex Offender*

    Are you a convicted sex offender

    1. Yes
    2. No
42. If You Answered Yes to Any of the Above
    If yes, please explain in detail the date, location, action taken, and final outcome of the case.
43. 
    
47. Why do you want to attend the CPA?*
49. Applicant Release Form*

    I am presently residing at the address listed above and do hereby consent to the background investigation and authorize a review of all records, or any part thereof concerning myself, by and to a duly authorized officer of the Lancaster Police Department, Lancaster, Ohio, whether the said records are public or private, and including those that may be deemed to be privileged or confidential. I understand that all information will be kept confidential. I also understand that should any statement I have made be proven to be false, misleading, or erroneous, it may result in rejection of my application or discharge from the academy. I grant the Lancaster Police Department and the Citizen Police Academy Alumni Association permission to use my likeness in photographs or video in any publications promoting the Lancaster Police Department or its programs, the Lancaster Police Citizen Police Academy Alumni Association and/or any of its programs.

    1. I Understand and Consent
    2. I Do Not Understand or Do Not Consent
51. Release and Hold Harmless Agreement and Affirmation For the Lancaster, Ohio Citizen Police Academy (CPA)*

    I am presently residing at the address listed above and hereby confirm that I have been fully informed of the nature, scope, and purpose of the Lancaster Citizen Police Academy prior to enrolling in the course. By enrolling and signing this document, I certify that I am cognizant of all the inherent dangers of police work and of the basic safety rules for activities connected herewith. I understand that it is not the purpose of this course to teach safety rules, nor is it the function of the instructors to serves as guardians of my safety, and I full understand the risks involved in this course. I further understand and agree that neither the City of Lancaster, Ohio nor its agents and employees of the Lancaster Police Department, the Chief of Police, or any individual officer or CPA instructors may be held liable in any way for any occurrence in connection with my participation in the Citizen Police Academy which may result in injury, death, or other damages to me, my family, heirs, or assigns. In consideration for being allowed to enroll in this course, I hereby personally assume all risks in connection with the course, and I further release the City of Lancaster, Ohio, its agents and employees, the Lancaster Police Department, the Chief of Police, the individual officers, CPA instructors or assistants, including but not limited to the persons mentioned for any injury or damage which may befall me while I am enrolled in the Citizen Police Academy, including all risks connected herewith, whether foreseen or unforeseen: and further to save and hold harmless the City of Lancaster, Ohio, its agents and employees, the Lancaster Police Department, the Chief of Police, individual police officers, or CPA instructors from any claim by me, or my family, estate, heirs, or assigns, arising out my enrollment and participation in this course.

    1. I Understand and Consent
    2. I Do Not Understand or Do Not Consent
53. Lawful Age and Legally Competent*

    I further state I am of lawful age and legally competent to sign this affirmation and release; that I understand the terms herein are contractual and not a mere recital and I have signed this document of my own free will. I am fully informed of the contents of this affirmation and release by reading it before I signed it.

    1. Yes I am of Legal Age and Competent
    2. No I am not of Legal Age or Competent
54. Background Investigation*

    I do hereby consent and agree to a background investigation and review of all my records, public and private, including social media.

    1. Yes - I Agree
    2. No - I Do Not Agree
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit Submit and Print

* indicates a required field