2. 
4. First Name

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5. Last Name

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7. Address

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9. City

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10. State

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11. Zip Code

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13. Phone Number

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15. Email Address

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17. Years Living in Haines City

    Type number of years living in Haines City

19. Occupation

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21. Race/Ethnicity

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23. Date of Birth

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25. Food Allergies/Restrictions

    Type your food allergies or include if you are vegan or vegetarian.

27. Personal History – Please tell us about yourself, ex. interests, accomplishments, community involvement, etc.

    Type your personal history

29. Please list any civic, professional, social or other organizations in which you are a member. If you are new to Haines City, you may include activities from your prior residence.

    Type a list of your memberships in organizations

31. What do you hope to learn from the Citizens Academy?

    Type what you hope to learn from the Citizens Academy

33. I hereby give my permission for the City of Haines City to use any still photography or video footage in which I may appear for whatever purpose(s) deemed appropriate. I do this voluntarily and with the understanding there is no remuneration. In addition, I release Haines City from any liability involved in transporting me to and from Haines City properties.

    Do you agree?

    1. yes
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35. 1. Receive an email copy of this form.
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