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 100% of survey complete.

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* 1. What is your last name?

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* 2. What is your first name?

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* 3. What is your middle name or initial?

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* 4. What is your house number and street address?

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* 5. What is your city?

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* 6. What is your state?

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* 7. What is your zip code?

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* 8. What's the best phone number to contact you?

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* 9. What is your email address?

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* 10. What are the last four digits of your SSN?

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* 11. What is your race or ethnicity?

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* 12. What is your gender?

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* 13. When were you born?

Date

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* 14. What is your driver's license number?

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* 15. What state issued your driver's license?

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* 16. What is your occupation?

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* 17. Who is your employer?

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* 18. What is your employer's address?

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* 19. Who is your emergency contact?

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* 20. What is your relation to your emergency contact?

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* 21. What is your emergency contact's address?

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* 22. What is your emergency contact's phone number?

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* 23. Have you previously attended any Community Academy programs offered by the City of Alexandria?

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* 24. Are you able to commit to the full 4-week program?

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* 25. Why do you want to participate in the Sheriff's Community Academy?

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* 26. Where did you hear about the Sheriff's Community Academy?

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* 27. FRAUD AND WILLFUL MISREPRESENTATION STATEMENT

- I certify that there are no willful misrepresentations, omissions, or falsifications in the foregoing statements and answers to the questions.

- I understand that any omission or false statement on this application shall be sufficient cause for rejection or dismissal from any Sheriff's Office program.

- I fully understand that all Sheriff's Office programs are non-confrontational and that at no time am I to take any type of enforcement action against anyone. If I observe suspicious and/or criminal activity, I will report it to the appropriate law enforcement authority.

I acknowledge as part of acceptance in the Sheriff's Community Academy, I will be required to:

- Attend all scheduled events. Contact the Sheriff's Office if unable to attend session.

- Abide by all rules and regulations set forth by the Sheriff's Office and the City of Alexandria.

- No weapons are allowed during any scheduled portion of the Sheriff's Office Academy.

- Provide my own transportation and insurance.

- Dress appropriately. Casual attire is acceptable for most events.

Additionally, I understand and agree with the following:

- No weapons of any kind are allowed during any scheduled portion of the Sheriff’s Community Academy.

- Participants in the Sheriff’s Community Academy consent to the Sheriff’s Office use of any photographic or video recording of the activity in any marketing or promotional material.

- Participants in the Sheriff’s Community Academy are not permitted to take photographs, video recordings or audio recordings inside the Adult Detention Center or inside the Alexandria Courthouse.

- The Alexandria Sheriff’s Office maintains a no hostage negotiation policy for all employees, volunteers, contract workers and visitors.

- That information regarding Detention Center inmates is confidential and is not to be disseminated in any fashion or form. Should I receive any inquiries about inmates, or receive inquiries from the inmates themselves, I am to refer the person making the inquiry to a member of the Alexandria Sheriff's Office. I understand that I am neither to pass nor receive any material from any inmate.

- I acknowledge that while the Detention Center is a secure environment, I am requesting to tour a facility that houses individuals charged with or convicted of violent offenses or who may display inappropriate behavior.

- I further acknowledge that the Alexandria Detention Center has a no hostage policy. Should I be taken hostage, I understand and acknowledge that negotiations for my release will not include the release of any inmate from custody.

- I further understand that the Alexandria Sheriff's Office will conduct a thorough background investigation which may include but will not be limited to fingerprinting and/or any criminal history check.

NOTE: Please enter your full legal name below. Typing your full legal name will serve as a signature for this request.

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* 28. WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT

The undersigned, for and in consideration of being a participant in the Alexandria Sheriff's Community Academy of the City of Alexandria, and allowed use of the City of Alexandria property, equipment and services, including but not limited to the weapon firing range, and recognizing that such activity involves certain inherent risks and dangers to my property and person, do hereby agree to assume the risks attendant to such activity, to include property damage and physical injury from such services, and do hereby release and hold harmless the City of Alexandria, the Sheriff of Alexandria, the Alexandria Sheriff's Office and its agents, and employees, in both their public and private capacities, from any all liability, claims, suits, demands or causes of action which may arise.

It is further agreed that the execution of this release shall not constitute a waiver by the City of Alexandria of defense of governmental immunity, where applicable or any other defense recognized by the Courts of this Commonwealth.

NOTE: Please enter your full legal name below. Typing your full legal name will serve as a signature for this request.

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