Jackson County Citizens Academy Application
Thank you for applying to Jackson County Citizens Academy. Applicants must be 18 years old and resident of Jackson County.
Please print legibly and complete the entire application. All applications are reviewed, you will be notified if selected to participate.
Position Desired:
Jackson County Citizens Academy Applicant
Class Start Date:
Full Legal Name: (Please Print):
Street and Mailing Address:
Zip Code:
Home Phone Number:
Cell Phone Number:
Email Address:
Driver’s License State and Number:
Last 4 Digits of SSN:
Ethnicity: White Black Am. Indian Asian/Pacific Islander
Male Female
Are you currently employed by Jackson County? Yes No
If yes, in what department?
What do you hope to gain from attending the Citizens Academy?
Reference & Background Information
Please provide professional or personal references to include previous employers, volunteer supervisors, program instructors or other personal references.
The Citizens Academy offers a unique opportunity for county residents to get an in-depth look at county government.
Reference Name:
Relationship to you:
Reference Name:
Relationship to you:
Have you ever been convicted or pleaded guilty before a court for any federal, state, or municipal criminal offense? (Not including minor traffic misdemeanors)
If yes, please provide details below: (Include state, county, date of offense, and details of conviction)
Consent to Perform Background Check: In connection with my application and desire to engage in Citizens Academy, I have been advised and I hereby consent
and authorize Jackson County and its agent, at any time during or subsequent to my application process to conduct a background check that may include a criminal
record check and such additional verifications and reference checks as deemed necessary. I do hereby consent to Jackson County’s use of any information provided
during the Citizens Academy application process to perform related background check.
I agree to release, indemnify, and hold harmless Jackson County and any agency used by Jackson County with regard to any information provided by the agency. I
have been informed that I will have a reasonable opportunity to clear up any mistaken information provided by the agency within a reasonable time frame
established within the sole discretion of Jackson County.
Further, all applicants are required to inform the county within five (5) days after he or she is convicted for violation of any federal or state laws. Such convictions
are to be reported to the County Manager.
Jackson County will accept background checks completed by other entities for Citizens Academy applicants if the entity is willing to release copy. If another
entity is providing copy of completed background check, please provide the organization’s name and contact person.
Organization Name: ____________________________________________________________________ Contact Person: _______________________________________ Phone: ________________________________
Certification of Information Provided: I hereby certify and attest that the information provided is true, correct, and complete. I understand that any falsification of
information will disqualify me for the Jackson County Citizens Academy. MEDIA/PHOTO RELEASE: I do hereby consent to and authorize the use and reproduction, in print
or electronic format, of photographs and digital images of me to be used for any purpose (web pages, social medial or promotional purposes) without compensation to me.
All photographs and digital images are owned by County of Jackson. By signing below I am expressly releasing County of Jackson, its agents, employees, licensees, and
assignees from any and all claims which I may have for invasion of privacy, right of publicity, defamation, copyright infringement, or any other cause of action arising out of
the use, adaption, reproduction, distribution, broadcast, or exhibition of such photographs and digital images. I hereby acknowledge that I have read and understand the
terms of this release.
Applicant Signature: Date:
If ap
proved for Citizens Academy, we request each individual provide us with an emergency contact:
Emergency Contact Name: Emergency Contact Phone:
Background Check Conducted: Yes No Background Findings: Acceptable Unacceptable
Reviewed By: (Staff Signature) Date: