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2. 
4. Personal Information
6. First Name*
7. Middle Name
8. Last Name*
9. Suffix
   -- Select One --IIIIIIVVJr.Sr.
11. Nickname
12. Age*
13. Sex*

    1. Male
    2. Female
14. Date of Birth*
    Date of Birth
16. Drivers License/Identification Number
17. Driver's License State
19. Address1*
21. City*
22. State*
23. Zip*
25. Home Phone Number*
26. Cell Phone Number
28. Email Address*
30. If under 18 Parent's or Guardian's Name(s)
32. If under 18 Parent or Guardian Cell
33. If under 18 Parent or Guardian - Email
35. Emergency Contacts Name*
36. Emergency Contact Relationship*
37. Contact's Phone Number*
39. Emergency Contact Name
40. Emergency Contact Relationship
41. Phone Number
43. Health Insurance Provider*
45. Have you ever been arrested or charged with an offense? If so, explain:
47. If under 18, Have you ever had any school disciplinary issues? If so, explain:
49. Authority to Conduct Background Check*

    By placing my electronic signature below, I hereby authorize the Louisa County Sheriff’s Office to examine the records available to the Louisa County Sheriff's Office in connection with my application for this community outreach program (CLEA, LEAP, TCLEA, TDC). I hereby authorize the release of any information that the Louisa County Sheriff’s Office may request. A copy of this release shall be as valid as the original document. I also understand and agree that all information received by the Louisa County Sheriff’s Office in connection with my application and background is confidential and may be disclosed to me.

    1. I agree
51. Electronic Signature
52. Date
    Date
54. Are you interested in a career in any phase of the Criminal Justice System? If yes, please describe:
56. Why do you want to attend this program? Please Describe:
58. Volunteer Experience
    List any past volunteer experience you may have.
60. Instructions
    Applicants should not assume they have been selected until they have received confirmation from one of the Program Coordinators. More information will be provided at that time. If you have medical conditions/previous injuries and/or Medications please contact one of the Program Coordinators prior to filling out application.
62. Shirt Size*

    1. Adult Small
    2. Adult Medium
    3. Adult Large
    4. Adult XL

    1. Adult XXL
    2. Adult XXXL
    3. Ladies Small
    4. Ladies Medium

    1. Ladies Large
    2. Ladies XL
    3. Ladies XXL
    4. Ladies XXXL

    1. Child XS
    2. Child Small
    3. Child Medium
    4. Child Large
64. Photo Use Release Form*

    By checking the "I agree" box below, you hereby grant and authorize the Louisa County Sheriff's Office the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me by the Louisa County Sheriff's Office to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languates, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of the Louisa County Sheriff's Office and will not be returned. I hereby hold harmless, and release the Louisa County Sheriff's Office from all liability, petitions, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.

    1. I agree.
66. Electronic Signature*
67. Date*
    Date
69. Applicant's Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
71. Applicant's Electronic Signature*
72. Date*
    Date
74. If under 18 Parent / Guardian Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
76. If under 18 Parent / Guardian Electronic Signature
77. Date
    Date
79. Parent / Guardian Name
Leave This Blank:


81. 1. Receive an email copy of this form.
82. Email address

    This field is not part of the form submission.

83. Submit

* indicates a required field