*DATE OF APPLICATION

*APPLICANT'S FULL NAME

*DATE OF BIRTH

*SOCIAL SECURITY NUMBER

*DRIVER'S LICENSE STATE/NUMBER

*EMAIL ADDRESS

*HOME ADDRESS

*CELL PHONE NUMBER

EMPLOYER'S NAME (IF APPLICABLE)

EMPLOYER'S ADDRESS (IF APPLICABLE)

EMPLOYER'S PHONE NUMBER

*BRIEFLY DESCRIBE YOUR INTEREST IN APPLYING FOR ENROMMENT IN THE CITIZEN'S ACADEMY

I, the undersigned, affirm that the above information is true and accurate. I authorize the Keizer Police Department to conduct a background investigation on my suitability as a Citizen’s Academy student, and I understand that any information of an adverse nature may disqualify me. I understand that this application does not constitute a contract or promise of enrollment and that my enrollment may be denied or revoked at the discretion of the Keizer Police Department.

*SIGNATURE

*DATE

KEIZER POLICE DEPARTMENT CITIZEN’S ACADEMY RELEASE AND WAIVER OF RIGHTS

I, the undersigned, as an individual, have read and understand the contents and nature of this agreement. The City of Keizer, its officers, employees, volunteers, and agents will be known as the City of Keizer in the remainder of this agreement.

• It is my desire, and intention to obtain enrollment and attend the Keizer Police Department Citizen’s Academy is a voluntary program that is free of charge.

• The above-described activities may expose me and other members of the program to a variety of hazards. Dependent upon the nature of each activity, the risk of injury attendant with the activity, whether foreseen or unforeseen, cannot be eliminated.

• In the event of an emergency, accident, or illness, I authorize the City of Keizer and its employees to administer emergency medical care to me, if deemed necessary, to secure emergency medical services and incur expenses for which I will be responsible for payment. My signature below hereby represents that I have read, understand, and consent to this agreement.

• If I use a personally owned vehicle in the course of my duties, I agree and represent that I have automobile liability insurance in accordance with Oregon law. I understand I must possess a valid driver’s license and that I will immediately inform the City of Keizer if either my driver’s license or insurance is suspended, revoked, or canceled.

• I further agree that, despite this Release and Waiver of liability, Assumption of Risk and Indemnity Agreement, if I or anyone on my behalf makes a claim against the City of Keizer, I will indemnify, save and hold harmless the City of Keizer from any litigation expenses, attorneys’ fees, loss, liability, damage, or costs that the City of Keizer may incur as a result of such action.

• I agree to not perform any services unless I have been fully trained to do so. I agree to assume full responsibility for my own safety.

• I grant permission to the City of Keizer to use my likeness in a photograph in any and all of its publications and promotions without consideration or compensation.

By signing this release form, I agree to waive and discharge any and all claims and to hold harmless the City of Keizer, officers, employees, volunteers, and agents from any claim for injury or damages that may arise from, or in connection with my participation in the activity described above.

This agreement is intended to be as broad and inclusive as is permitted by law. I understand this agreement and I have read this agreement in its entirety and I freely and voluntarily assume all risks and responsibilities associated therewith, and notwithstanding such, I agree to perform pursuant to this agreement and be bound by its conditions. By signing below, I agree that I understand and consent to this agreement. THIS IS A RELEASE AND WAIVER OF RIGHTS – READ BEFORE SIGNING.

*SIGNATURE

*DATE