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2. Name*
3. Email Address*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Date of Birth*
14. Shirt Size*
    -- Select One --SMLXLXXLXXXL
15. Occupation*
17. Place of Employment*
18. Address of Business*
20. Have you ever been arrested before?*
    -- Select One --YesNo
21. If yes, please give details
25. Please give two character references with a telephone numbers
27. Name*
28. Phone Number*
30. Name*
31. Phone Number*
35. RELEASE, ASSUMPTION OF RISK AND INDEMNIFICATION AGREEMENT FOR CITIZEN FIRE ACADEMY CLASS
37. Initial*

    I authorize the City of White Settlement to take photographs or video footage of me during the Academy. I agree that any photos and video footage taken during the Academy are the property of the City of White Settlement and for the sole use of the City of White Settlement as it may desire. I further specifically authorize the use of any photographs or video footage taken during the Academy in any City of White Settlement publications, on White Settlement Television, or on an official City of White Settlement Website.

38. Initial*

    In case of accident, injury or sudden illness while enrolled in the Academy, I authorize and consent to any first-aid or emergency medical care that is necessary to be administered to me including transportation to a local medical facility.

40. RELEASE AND WAIVER OF LIABILITY AND INDEMNIFICATION AGREEMENT
42. Initial*

    In consideration of the use and availability of the services and facilities by me, I agree to release, waive, and discharge any and all claims and damages for personal injury, death, or property damage that I have and that may hereafter accrue to me while participating in the Academy. This agreement is intended to discharge, in advance, the City, including its officers, employees, agents, co-sponsors or volunteers, from any and all liability that may arise while I am participating in the Academy, even if that liability arises out of negligence or carelessness on the part of the City, or its officers, employees, agents, co-sponsors or volunteers. I further agree to indemnify and hold harmless the City, including its officers, employees, agents, co-sponsors or volunteers, harmless from, against, and for any claims, suits, judgments, proceedings, losses, liabilities, damages, or expenses arising out of any injury, death or property damage that occurs while participating in the Academy, even if the injury, death or property damage arises out of the sole negligence of the City, or its officers, employees, agents, co-sponsors or volunteers. I understand that participation in the Academy involves an element of risk and that there is a real potential for injuries or accidents. Knowing and understanding those risks, I hereby agree to assume those risks. I further agree that this agreement to waive and release the City from liability, to indemnify and hold harmless the City, and to assume the risks of participating in the Academy is to be binding on my heirs and assigns.

44. DIGITAL SIGNATURE (TYPE YOUR NAME BELOW TO DIGITALLY SIGN DOCUMENT)*

    I HAVE CAREFULLY READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW. I UNDERSTAND THAT THIS IS A BINDING CONTRACT BETWEEN THE CITY OF WHITE SETTLEMENT AND ME. I UNDERSTAND BY ENROLLING IN THE CITIZENS FIRE ACADEMY, I AM SUBJECT TO A BACKGROUND CHECK, WHICH INCLUDES A CHECK OF ANY ARREST RECORD, DRIVING RECORD, WARRANT CHECK AND CRIMINAL HISTORY CHECK.

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46. 1. Receive an email copy of this form.
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