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2. Citizen's Academy Application Form
4. PERSONAL INFORMATION
6. First Name*
7. Last Name*
9. Mailing Address*
11. Home Address*
13. City*
14. State*
15. Zip Code*
17. Phone Number*
19. Email Address*
21. Preferred Method of Contact*

    1. Phone
    2. Email
25. In Case of Emergency, Please Notify:
27. First Name*
28. Last Name*
30. Phone Number*
32. Physical Limitations (Note: ADA Requests)*
34. How did you find out about this program?*
36. What are you hoping to learn and/or gain from this program?*
38. WASHOUGAL CITIZEN'S ACADEMY RULES:

    1. Arrive on time for each session and stay for the duration. (6:00pm-8:00pm)

    2. Make every effort to attend all 6 sessions. Only one missed session is allowed for successful completion of the program.

    3. Photos, video and information of participants obtained during the program may be used by the city in marketing efforts.

    4. Interact with classmates, participate in activities and have fun!

40. I HAVE READ AND UNDERSTAND THE CITIZEN'S ACADEMY RULES AND AGREE TO ADHERE.
42. First Name*
43. Last Name*
45. Electronic Signature*
47. DATE*
    DATE

    DATE
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field