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2. First Name*
3. Last Name*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. Email Address*
14. If aged 14-17, please attach a letter of recommendation or reference.

    Reference must be from an adult 18 years or older.

16. The benefits of Citizen's Academy are maximized when all five days are attended. Please verify the days you will be joining us:*

    1. October 12
    2. October 19
    3. October 26
    4. November 2
    5. November 9

    At least four of the days are required to graduate from the Academy.

18. Why are you interested in participating in the Academy?
20. We will be providing dinner each session. Do you have any dietary restrictions?
22. Do you have any accommodation needs? If yes, please list them.
24. Are there any specific topics or areas of interest you would like covered in the Academy?
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26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit

* indicates a required field