2. 
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Daytime Phone Number
16. Cell Phone Number*
18. Email Address*
20. Date of Birth*
    Date of Birth
21. High School*
22. Grade*
    -- Select One --9th Grade10th Grade11th Grade12th Grade
24. Parent/Guardian Name*
25. Phone*
27. How did you first hear about the Teen Citizens Police Academy?
29. Give the names and email of two school staff references*
31. Student Acknowledgement

     As a participant in the Murfreesboro Teen Citizens Police Academy, I acknowledge that I am expected to behave appropriately.  Excessive horseplay, use of foul language, disruptive or other inappropriate behavior may result in being dismissed from the program.  I also understand I am not allowed to take photographs or recordings of any police activity without expressed permission.  

33. Student Electronic Signature Disclosure*
    -- Select One --I agreeI do not agree

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

35. Parent Acknowledgement

    As parent/ guardian of the above participant, I also agree they may be dismissed for in appropriate behavior as stated above. I furthermore hereby release and covenant not to sue, the City of Murfreesboro, Tennessee and its officers, employees, and agents from or for any and all liability for claims or causes of action for damages, expenses or compensation of any kind or nature whatsoever resulting from, caused by or growing out of the above participant’s participation in this program. I also hereby authorize photographs and or video documentation to be taken of the above participant which may be used to promote or further the Murfreesboro Police Department Teen Citizens Police Academy and may be used as such for media purposes. 

37. Parent/Guardian Electronic Signature Disclosure*
    -- Select One --I agreeI do not agree

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    
    

39. Non-Discrimination Policy
    • The City of Murfreesboro does not discriminate on the basis of race, sex, color, religion, national origin, age, disability or veteran status in the provision of services, in programs, activities or employment opportunities and benefits.
    • The City of Murfreesboro does not discriminate on the basis of disability in the programs and activities on which it operates pursuant to the requirements of the Americans With Disabilities Act of 1990, PUB. L. 101-36. 
      This policy extends to both employment and admission to and participation in the programs, services and activities of the City of Murfreesboro.

    THIS IS NOT AN EMPLOYMENT APPLICATION

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41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

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