Davis County Citizens Police Academy DCCPA APPLICATION FORM Step 1 of 3 - Course Previously Taken 0% Additional Application*Have you submitted an application before? YES NO Course Taken Before*Have you taken the Davis County CPA course before? Please Note: If you have taken the Davis County CPA course before this form will not take any further data as you are only permitted to take the course once. Yes No Name* First Last Address* Street Address Address Line 2 City ZIP / Postal Code Phone*DRIVERS LICENSE #* BIRTH DATE* MM slash DD slash YYYY SEX* MALE FEMALE Eye Color* Brown Blue Green Gray Hazel Amber Violet Red Please select your eye colorShirt Size* Small Medium Large XL 2X 3X 4x Please Select your shirt sizeEMPLOYER/SCHOOL NAME* Email* REFERRAL*How were you referred to CPA?Participation*Why do you want to participate in this class?MEDICINES*List any medications and/or allergies we may need to know about: Enter NONE if none.EMERGENCY CONTACT NAME* First Last EMERGENCY CONTACT PHONE*ARRESTS*Have you ever been arrested for a felony or are you currently on parole or probation? NO YES (A background check will be conducted on each applicant. Any intentional misrepresentation will be grounds for immediate dismissal.)AREEST INFORMATION*Please explain:I hereby acknowledge that I have completed the above information fully and accurately. I understand and give my permission, with respect to the Centerville Police Department and/or Davis County Sheriff’s Office, to conduct a background investigation to determine my suitability for admission to this program.SIGNATURE* Date*Enter today's date MM slash DD slash YYYY For more information, please contact Tricia Gallagher at 801-292-8441 MEDICAL SCREENING FORMIndividual's Name* First Last Individuals under consideration for attendance at the Citizen Police Academy must complete this medical screening questionnaire. 1. Do you now or have you previously been treated for or experienced: (Please Check)Heart Disease or Condition : YES NO Chest Pain: YES NO Frequent Fainting: YES NO Asthma: YES NO Emphysema: YES NO Chronic Bronchitis: YES NO Other Lung or Chest Problems: YES NO Perforated Eardrum: YES NO Seizure or Epilepsy: YES NO Diabetes: YES NO Heat Injury (last 12 months: YES NO Hyperventilation: YES NO Claustrophobia: YES NO Taking Narcotic Medication: YES NO Have an Open Wound or Sutures: YES NO High Blood Pressure: YES NO 2. Any question with a YES answer requires the individual to have medical screening by a licensed physician certifying the individual is in appropriate health to perform tasks such as:Arrest Control Techniques, Participating with Live Firearms, Volunteering for Pepper Spray, and Simulator Machines. NOTE: If pregnant,it is suggested the individual participate in a future class. Pregnancy disqualifies individuals from certain activities.3. Medical Screening Form and Physician Certification (if required) must be attached to application form.SIGNATURE:*
