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2. 
4. Personal Information:
6. Full Name (First, Middle, Last)*

   Enter your legal name as it appears on official documents.

   Include: First, Middle, and Last name.

8. Preferred Contact Number*

   Enter a 10‑digit phone number in this format:

   Example: 269-555-1234

9. Email*

   Enter a valid email address you check regularly.

   Example: name@example.com

11. Home Address (City, State, Zip)*

    Provide your full home address including:

    • Street address
    • City
    • State
    • ZIP code
13. Occupation*

    Enter your current job title or role.

    If retired or unemployed, type Retired or Unemployed

14. Employer*

    Enter the name of your current employer or organization.

    If none, type N/A

16. Work Address (City, State, Zip)

    Provide your work address including:

    • Street address
    • City
    • State
    • ZIP code

    If not applicable, type N/A

18. Shirt Size:*

    Select one shirt size from the options provided:

    • Small
    • Medium
    • Large
    • X-Large
    • XX-Large

    1. Small
    2. Medium
    3. Large
    4. X-Large
    5. XX-Large
20. Please list any dietary restrictions:*
22. Background Information:
24. Are you a U.S. citizen?*

    1. Yes

    1. No
26. Have you ever been convicted of a crime other than a minor traffic offense?*

    1. Yes

    1. No
28. If yes, please explain:
30. Please indicate how you first learned about the Citizens Police Academy program.*

    1. Internet Search
    2. Facebook/Social Media
    3. Flyer or Brochure Handout
    4. Referred by Friend/Neighbor
    5. Referred by Police Officer
    6. Other
32. Name of officer that referred you:
34. Name of friend/neighbor that referred you:
36. How did you learn about the Citizens Police Academy?
38. Briefly explain why you wish to be accepted into the Citizens Police Academy.*
40. What do you expect to learn from this experience?
42. Do you have any reservations concerning participation in any physically-challenging or stress-related activities as part of this academy? (Examples include simulated building searches, firearms demonstrations)
44. Please list any community groups or activities with which you currently are or have been involved.
46. References:

    Provide three references who are not family members. For each reference, include:

    • Full name
    • Phone number
    • Address
48. Name*
49. Contact Number:*
51. Address (City, State, Zip)
55. Name*
56. Contact Number:*
58. Address (City, State, Zip)
62. Name*
63. Contact Number:*
65. Address (City, State, Zip)
67. I attest that the above statements made on this application are true and complete. I authorize the Battle Creek Police Department to examine this information to evaluate my participation in the Citizens Police Academy, as well as run a driving and criminal history check to ensure that there are no disqualifiers to prohibit my participation in the Citizens Police Academy. I understand that the Battle Creek Police Department Citizens Police Academy does not certify or qualify citizens to perform any law enforcement services.*

    Type your full name to certify that the information provided is accurate and complete.

Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field