Upper Darby Township Police Department

							  Upper Darby Township Police Department
  Citizens Police Academy Application
  Spring 2010


  NAME______________________________________________________________



  STREET ADDRESS_____________________________________________________



  CITY, STATE, ZIP CODE________________________________________________



  DRIVER’S LICENSE NUMBER___________________________________________



  PHONE #__________________________________________________________



  ARE YOU 21 YEARS OF AGE OR OLDER?                   YES                        NO



  HAVE YOU EVER BEEN ARRESTED FOR A CRIME?                     YES                   NO



  The above information is true and correct to the best of my knowledge and abilities:.

  _________________________________________________________________________

  Applicant Signature                                                            Date

Waiver of Liability

I hereby release the Upper Darby Township Police Department, all officers, employees, elected and
appointed officials of Upper Darby Township, and the Upper Darby Police Department and all other
Upper Darby Township and Upper Darby Police personnel from any and all actions or causes of actions,
claims, liability, legal action, suits and demands which I now have or may ever have: or which my heirs or
representatives may have, resulting directly or indirectly from my involvement in the Upper Darby Police
Citizens Police Academy.

______________________________________________________________________________

Name                                                                          Date