UC DAVIS POLICE DEPARTMENT
COMMUNITY ACADEMY REGISTRATION FORM

THERE IS NO COMMUNITY ACADEMY THIS YEAR 2022. CHECK NEXT YEAR AROUND SEPTEMBER 2023. THANK YOU FOR YOUR INTEREST!

Community Academy Dates: Every Wednesday from October 6th to December 8th, 2021. (October 6, 13, 20, 27; November 3, 10, 17; December 1, 8)
Time: 5:30 pm – 7:30 pm -Place: EOC Meeting room

Thank you for your interest in the Police Community Academy! We are very happy you have decided to spend some time with us! Let's start...

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* 1. Registration Information:

Name

Email Address

Phone Number

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* 2. Additional Information:

Date of Birth:

Driver License/CA ID #:

Occupation: (students-staff- other)

Employer:

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* 3. Do you have any past arrests, convictions or pending court cases? (Include all misdemeanor and felonies. You do not have to include infractions- example traffic tickets.)

Yes

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* 4. If you answered "yes" to above question, please list below the DATE, AGENCY, CHARGE, AND DISPOSITION.

Date:

Agency:

Charge:

Disposition:

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* 5. Please, use this space to write additional information from question # 4:

BACKGROUND AUTHORIZATION:
I understand that a criminal background and warrant check will be conducted by the UC Davis Police Department as part of the application process. I hereby authorize any law enforcement agency to release to the UC Davis Police Department any and all information, which said agencies have about me, for the limited purpose of aiding the UC Davis Police in evaluation my eligibility for the participation in Community Academy. This authorization extends to any information, which said agencies or any of them may have about me, whether public, personal, or confidential. I received from these agencies. I hereby release, discharge, and agree to hold harmless the agencies, their agents and any person furnishing information from any and all liability arising out of furnishing and inspecting such documents and information.

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* 1. Registration Information:

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* 2. Additional Information:

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* 3. Do you have any past arrests, convictions or pending court cases? (Include all misdemeanor and felonies. You do not have to include infractions- example traffic tickets.)

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* 4. If you answered "yes" to above question, please list below the DATE, AGENCY, CHARGE, AND DISPOSITION.

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* 5. Please, use this space to write additional information from question # 4:

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* 6. Signature (full name)