CHISAGO COUNTY CITIZENS’ ACADEMY
Working in Partnership with our Community
2015 Application for Admission
Joint Effort Sponsored By
Chisago County Sheriff’s Office | Lakes Area Police Department
North Branch Police Department | Wyoming Police Department
CHISAGO COUNTY CITIZENS’ ACADEMY
Working in Partnership with our Community
Applicant Advisory
Due to the sensitive nature of some topics being presented in the Chisago County Citizens’ Academy, a criminal history background investigation will be conducted on all applicants applying for admission into the program. Applicants found to possess felony conviction will be denied.
Waiver of Responsibility
In signing this release, I acknowledge that I understand the intent thereof, and I hereby agree and will absolve and hold harmless the Chisago County Sheriff’s Office, Lakes Area Police Department, North Branch Police Department, and Wyoming Police Department, and any other parties connected with the Chisago County Citizens’ Academy Program in any way, singularly or collectively, from and against any blame and liability, misadventure, harm, loss, inconvenience or damage, hereby suffered, inflicted or sustained as a result of participation in the Chisago County Citizens’ Academy Program.
Print Name: ______
Signature: ______Date: ______
Photo Collection Authorization/Potential Use for
Law Enforcement, News, and Promotional Material
In accordance with the Minnesota Government Data Practices Act, this notice is to inform you that the Chisago County Citizens’ Academy Program may acquire data about you, including identifying information or photographs, for development and/or promotion of the program. This information is considered non-public or private data.
I hereby give permission to the Chisago County Citizens’ Academy Program sponsors to share photographic images of me with other law enforcement agencies as well as use them in news articles, and/or publish them in informational materials to promote future sessions of the program.
Print Name: ______
Signature: ______Date: ______
CHISAGO COUNTY CITIZENS’ ACADEMY
Application Procedure
To ensure a spot in the Chisago County Citizens’ Academy, please complete the following application/registration progress.
- Application.
Please complete the application and return it to the Chisago County Sheriff’s Office. Once your application has been received and processed, you will be notified of the application results.
- Letter of Acceptance.
Once your application has been processed and, if accepted, you will be sent a Letter of Acceptance/confirmation. Included with this letter will be the academy curriculum, which will include dates, times, and locations for each class.
INSTRUCTIONS
These instructions are provided as a guide to assist you in properly completing your application. It is essential that the information be accurate in all respects. It will be used as a basis for a criminal history background investigation that will determine your eligibility for the Chisago County Citizens’ Academy. All information on this Application for Admission will be kept confidential.
- This Application for Admission should be printed or typed legibly.
- If a question is not applicable to you, indicate N/A in the space provided.
- An accurate and complete Application for Admission will expedite the criminal history background investigation process of your application.
- Return the Application for Admission to the Chisago County Sheriff’s Office (see “1. Application.”). The application can be mailed to Chisago County Sheriff’s Office, 313 N Main St, Rm 100, Center City, MN, 55012.
CHISAGO COUNTY CITIZENS’ ACADEMY
Application for Admission
Applicant MUST BE 21 YEARS OF AGE or older to apply. Incomplete and/or unsigned applications will not be considered. Please print or type.
PERSONAL
Full Name: ______
Date of Birth: ______Social Security Number: ______
Address: ______
Email Address: ______
Home Telephone: ______Cellular Telephone: ______
Driver’s License Number: ______State of Issuance: ______
Occupation: ______Employer’s Name: ______
How long have you lived and/or worked in Chisago County: ______
Have you ever been arrested for, convicted of, or cited for an offense other than minor traffic violations? ___ If yes, explain in detail including date, charge, place, and action taken.
BACKGROUND
Please explain briefly why you wish to partake in the Chisago County Citizens’ Academy.
MEDICAL HISTORY
Is there any medical information you feel the sponsoring agencies should be aware of: ____
If yes, please explain.
MEDICAL TREATMENT PERMISSION
I, ______, hereby give my permission, consent and authorization for any reasonable medical treatment deemed necessary by emergency medical responders, hospital, or physician. In case of an accident, illness or emergency, I give permission for medical treatment to be given to me as deemed appropriate. I will assume responsibility for any treatment that is deemed appropriate and will assume financial responsibility for any medical bills.
EMERGENCY CONTACT
Name: ______Relationship: ______
Address: ______
Home Telephone: ______Cellular Telephone: ______
Please review your answers carefully before signing this Application for Admission.
I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the foregoing information. I understand any omission or false statement on this application may result in rejection of enrollment or dismissal from the Chisago County Citizens’ Academy.
I understand there will be a thorough criminal history background check completed on me.
Applicant’s Signature: ______Date: ______
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How did you hear about the Chisago County Citizens’ Academy? ______
Indicate T-shirt size: M L XL (If other size is needed, please indicate here :______)