Civicorps Corpsmember Academy Application Form With Cover Letter (Page 5 of 8) in pdf

Civicorps Corpsmember Academy Application Form With Cover Letter Page 5

CIVICORPS CORPSMEMBER ACADEMY

Master Agreement Form

Civicorps Corpsmember Academy is a program of CHOICE. When you sign this agreement, you are

agreeing that you choose this program over all others that you are entitled to attend or have your child

attend.

Applicant’s Name:

Effective Date:

______________________

Applicant’s Signature

Date

Parent/Guardian’s Signature (if Applicant is under 18)

Date

Interview / Photo Release Authorization

I give Civicorps the absolute right and permission to use and/or publish at any time my photographs, quotes and/or

textual descriptions of me in its promotional materials and publicity efforts. I understand that the photographs,

quotes or textual descriptions may be used in a publication, print ad, direct-mail, electronic media (e.g. video, CD-

ROM, web page), or other form of promotion. I release Civicorps, the photographer, their offices, employees, and

agents from liability for any violation of any personal or proprietary right I may have in connection with such use.

_________________________________________

___________________

Signature

Date

_________________________________________

___________________

Parent/Guardian’s Signature (if Applicant is under 18)

Date

Probation / Court Involvement Information

Have you ever been convicted of any offense?

Yes ___ No ___

Misdemeanor? _____

Felony? _____ Date(s): _____________________________________

Do you have any court dates pending?

Yes ___ No ____ Date(s): _________________

Are you currently on probation or parole? Yes ___ No ___ Until what date? __________

P.O.’s Name: _____________________________________ Phone __________________

Civicorps Corpsmember Academy Application Form With Cover Letter Page 5