ViPS Application « Rochester Police Department

Name*

FirstLast

Date of Birth*

Phone*

Address*

Street AddressAddress Line 2CityStateZip Code

Email

Preferred method of contact*

Do you have any previous work history?*

Please briefly explain your work history.*

Have you ever been convicted of a crime?*

If yes, please explain your criminal history.*

I give my permission to the Rochester Police Department, Rochester, Illinois, to conduct a background check to determine if I have a criminal record.*

I authorize any and all persons, employers, partnerships, corporations, and all civilian and government entities, military agencies, law enforcement agencies, private, City, County, State, and Federal entities to release, furnish and exchange any and all available information relating to me for the purpose of determining my suitability to be appointed as a member of the ViPS Program. This includes, but is not limited to, all information related to my character, integrity, reputation, conduct and behavior. This authorizes release to the Rochester Police Department. This release is in addition to, and intended to curtail or diminish, the authorization and immunity provided by statute. I DO HEREBY RELEASE from any and all liability, all persons or entities disclosing information pursuant to this release.*

Please check all of the duties that you would be willing to perform as a participant in the ViPS program.*

Parking cars during community events
Assist in traffic control
Assist in running Village information tent during 4th of July
Role playing during police trainings
Assist in putting up signs and marking parking lots for special events
Photography
Videography and video editing
Computer Graphics

Please indicate your shirt size.*

If other, please specify size.*

The information I have provided above is truthful and has been filled out to the best of my ability.*

Applicant's Electronic Signature*

PrefixFirstLastSuffix

I am*

Parental Consent

I give my child permission to participate in the Rochester Police Department's Volunteers in Police Service (ViPS) Program.*

Applicant's parent/guardian's electronic signature (required if applicant is under the age of 18) *

PrefixFirstLastSuffix