Village Academy Registration

Village Academy Application Form

Background Information

Legal Name*

Prior Names Used

Date of Birth*

Driver's License #*

State Driver's License Issued*

Address

Address*

How long have you lived at your present address?*

Previous Address (If less than 5 years at your present address)

Previous Address

Occupation*

Employer*

Contact Information

Phone Number*

Email Address*

Emergency Contact

Full Name*

Phone Number*

Criminal Background

Have you ever been convicted of a crime?*

If yes, explain:

Participation Permit & Promise to Release

By submitting your application, you agree to the following:

In consideration of the benefits that I will receive from my participation in the Burr Ridge Village Academy, I, for myself, my heirs and assigns, hereby release the Village of Burr Ridge, public officials, agents, and employees from any liability, claims, demands, actions and causes of action which I may hereafter have on account, any injuries and/or damage to me or my property, or my death, arising out of or related to any happening or occurrence while I am participating in the academy. For the same consideration, I agree to hold the Village of Burr Ridge and said persons harmless from such liability, claims, demands, actions, or causes of actions. The terms thereof shall be in full force during my participation in the Burr Ridge Village Academy.

I hereby acknowledge that I have completed the information fully and accurately. I understand and give my permission with respect to the Burr Ridge Police Department to conduct a background investigation to determine my suitability for admission to this program. I understand that the Village of Burr Ridge and its representatives have the right to exclude an applicant with a less than exemplary police record whose participation is deemed not to be in the best interest of the Village of Burr Ridge and/or the applicant.