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Survey/Form Review
Citizen Police Academy - YOUTH
Please answer all questions, incomplete applications may not be processed. Please do not leave blank lines on the application, enter N/A or NONE where applicable. Applicants must attend school or live in the City of Richardson.

Please enter your full legal name.
First Name:
Middle Initial:
Last Name:
Home Address:
Street:
City:
Zip:
School
Name:
Grade in '15 - '16 School Year:
Phone #:

T-shirt size (participants will receive a free t-shirt to be worn at the graduation ceremony):
Date of Birth (Please enter in this format, MM/DD/YYYY):

Sex:
Texas Driver's License Number:

Email Address (For you to receive class information):

Emergency Contact
Name:
Phone#:
Relationship:
Parent/Legal Guardian
Name:
Phone #:
Address:
Email:
Please state why you are interested in attending the RPD Youth Citizen Police Academy:

Describe any community/recreational/extra-curricular activities in which you have participated (sports, clubs, church, etc.):

Have you ever been terminated or fired from a job or other employment, or been asked to resign? If yes, please explain:

Have you ever been convicted of any criminal law, other than a traffic violation? If yes, please explain:


Recommendations
Please list two personal recommendation that are not relatives and do not live with you (e.g. Teacher, Principal, Counselor, or School Resource Officer).
First Reference Name:
First Reference Phone #:
First Reference Email:
Second Reference Name:
Second Reference Phone #:
Second Reference Email:

By submitting this application, you certify that all information provided in this application is true and complete. You understand that any false information or omission may disqualify the applicant from further consideration for acceptance in the Richardson Police Department Youth Citizen Police Academy and may result in dismissal once accepted into the program. You understand that participation in the program is a privilege and this application for acceptance to the Richardson Police Department Youth Citizen Police Academy does not create an express or implied acceptance into the Academy nor guarantee acceptance for any definite period of time. If accepted, you understand that the acceptance and continued participation of the applicant in the Youth Citizen Police Academy is at the discretion of the Richardson Police Department and participation may be terminated at any time.
The Richardson Police Department may take photographs and video of students participating in our Youth CPA program. These photos and videos are used for promotion of the program to the public. The Photo Release agreement below is used to give permission for us to do this. If you have any questions about this, you can contact our Crime Prevention Unit at 972-744-4955 and we would be a happy to speak with you. PHOTO RELEASE - I hereby authorize and consent to the use of my visual image by the City of Richardson for appropriate purposes, including but not limited to: still photography, videotape, electronic and print publications, and websites. I give this consent with no claim for payment. *
By submitting this application, you authorize the Richardson Police Department to conduct a criminal history background investigation, including convictions, pending charges, and outstanding warrants of the applicant. You understand that all available police and criminal records will be checked and that information will be used solely for determining eligibility of the applicant for participation in the Youth Citizen Police Academy. All information is to remain confidential as required by applicable state and federal law.
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