Citizen Police Academy Application

Citizen Police Academy Application

Buffalo Grove Police Department

2019 Citizen Police Academy Application 

Name:  

Address:  

DOB:  

Telephone numbers:    

Email:  

Drivers License Number:  

Occupation:  

In case of an emergency, please contact the following:

Name:    

Relationship:  

Address:     

Phone:  

 

Village of Buffalo Grove
Participant Liability Waiver and Hold Harmless Agreement

Please read this form carefully and be aware that by registering for and participating in this program, you will be waiving your rights to all claims for injuries you might sustain arising out of this program and you will be required to indemnify, hold harmless and defend the Village of Buffalo Grove for any claims arising out of participation in the Buffalo Grove Citizens Police Academy Program.

Risk of Injury: “As a participant in the program, I recognize and acknowledge that there are certain risks of physical injury, including but not limited to adverse and stressful situations accompanying law enforcement activities: heart attacks, strokes, heat stress, sprains, broken bones and torn muscles or ligaments and I agree to assume the full risk of injuries, including death, damages, or loss which I may sustain as a result of participating in any and all activities associated with this program.”

Waiver of Injury Claim: “I agree to waive and relinquish any and all claims I may have arising out of, connected with, or in any way associated with the activities of the program.”

Release from Liability: “I do hereby fully release and discharge the Village of Buffalo Grove and its officers, agents and employees from any and all claims from injuries, including death, damage or loss which I may have or which may occur on account of participation in this program.” (Continued on reverse side) Indemnity and Defense: “I further agree to indemnify, hold harmless and defend the Village of Buffalo Grove and its officers, agents and employees from any and all claims from injuries, including death, damages and loss sustained by me arising out of, connected with or in any way associated with the activities of the program.”

Criminal History Check: “I do hereby grant permission for a law enforcement records check to be performed. The undersigned waives all right of privacy regarding criminal history information, understanding that all Citizen Police Academy records are confidential. I understand that should it be determined that I have a criminal arrest record I will not be allowed to participate in the Citizen Police Academy.”

As a way of promoting the Citizen Police Academy, photographs and video imagery will be taken during academy sessions which might be used on the Village of Buffalo Grove’s Web site or appear in local newspapers. If you do not wish to have your photograph or video image appear on the web site or in the newspaper, please check this box.

I have read and fully understand and agree to the above stated conditions of participation in the Buffalo Grove Police Department’s Citizen Police Academy.  

 

Please enter your name as you would like it to appear on the Graduation Plaque. 



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