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Weatherford Citizen University Application

2. 
4. Instructions:
   Please complete application below for consideration to Weatherford Citizen University. Applicants must be registered voters in the City of Weatherford, a resident for at least one year, 18 years of age and not running for local political office during the 10 month program. Applicants will be notified if selected. Thank you for your interest in Weatherford Citizen University 2017.
6. First Name*
7. M.I.*
8. Last Name*
10. Phone Number*
11. Cell Number
12. Email*
14. How many years have you been a Weatherford resident?*
16. Physical Address:
18. Street Number*
19. Street Name*
20. Street Type*
21. Apt #
23. City*
24. State*
25. Zip*
27. MAILING ADDRESS IS:

    Check box only if mailing address is same as physical address.

    1. Same as physical address.
29. Mailing Address:
31. Address*
32. City*
33. State*
34. Zip*
36. Voter Information:
38. Are you a registered voter?*
    -- Select One --YESNO
39. What is your Voter ID number?
41. Employer's Information
43. What is your occupation?*
44. Who is your employer?*
46. Employer Address
47. City
48. State
49. Zip
51. What is your Polo Size?*
    -- Select One --SmallMediumLargeXLXXL
53. Please complete questions below:
55. What activities/organizations do you participate in?*
57. Why do you want to participate in the Weatherford Citizen University?*
59. Identify three issues you feel are important to Weatherford and/or your key areas of interest?*
    This information will be provided for class presenters.
61. What do you see as positives for you living in Weatherford?*
63. How did you hear about Weatherford Citizen University?*

    1. City Website
    2. City Employee
    3. Newspaper
    4. Friend
    5. Colleague
    6. Other
65. If other, please explain.
67. Authorizaton to Use Image*

    I hereby consent to my photograph being taken or image recorded by the City of Weatherford in connection with Weatherford Citizen University (WCU) regular meetings and activities. Furthermore, I authorize the use, copyright or publication of my name, image or voice as may be captured by photograph, video or audio recording while attending or participating with the Weatherford Citizen University (WCU), in any medium, for any purpose, including illustration, promotion, marketing or advertisement.

    1. YES
    2. NO
69. Applicant Agreement*

    As an applicant for the 2016-17 Weatherford Citizen University (WCU), you understand the importance of being an active participant in WCU classes and activities. If selected, you agree to do the following: Attend regular classes. Contribute ideas and energy to WCU classes and activities. Contact the WCU Staff Liaison in advance if you are unable to attend class. Check e-mails regularly and promptly reply or acknowledge receipt. You acknowledge that you are available to participate in classes and activities required for graduation. You understand that each participant must complete a minimum of eight sessions of the ten to graduate from the program and no make-up sessions will be available for missed sessions. Applicants must be registered voters in the City of Weatherford, a resident for at least one year, 18 years of age and not running for local political office during the 10 month program. Twenty-five (25) residents will be chosen to participate. Spouses will not be allowed to participate in the same University class. By checking the box below, this is your online signature, and you agree that you are, in fact, the person named above, and that you are the person making this request on the date provided above. You also certify that all information on this form is represented accurately. The applicant further authorizes the City Council, or its designee, to verify any information. The applicant agrees to release and hold harmless the City from all claims incident to the verification of information contained herein. All information is considered public pursuant to the Texas Public Information Act.

    1. Agree
71. If not selected for the 2016-17 University, would you like your application to be kept on file for next session?*

    1. YES
    2. NO
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

    This field is not part of the form submission.

75. Submit Submit and Print

* indicates a required field