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Sheriff's Office Community Program Application

  1. Footer ID

  2. Personal Information

  3. Sex*

  4. Authority to Conduct Background Check*

    By placing my electronic signature below, I hereby authorize the Louisa County Sheriff’s Office to examine the records available to the Louisa County Sheriff's Office in connection with my application for this community outreach program (CLEA, LEAP, TCLEA, TDC). I hereby authorize the release of any information that the Louisa County Sheriff’s Office may request. A copy of this release shall be as valid as the original document. I also understand and agree that all information received by the Louisa County Sheriff’s Office in connection with my application and background is confidential and may be disclosed to me.

  5. List any past volunteer experience you may have.

  6. Instructions

    Applicants should not assume they have been selected until they have received confirmation from one of the Program Coordinators. More information will be provided at that time. If you have medical conditions/previous injuries and/or Medications please contact one of the Program Coordinators prior to filling out application.

  7. Shirt Size*

  8. Photo Use Release Form*

    By checking the "I agree" box below, you hereby grant and authorize the Louisa County Sheriff's Office the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures or video taken of me by the Louisa County Sheriff's Office to be used in and/or for legally promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalists, websites, social networking sites and other print and digital communications, without payment or any other consideration. This authorization extends to all languates, media, formats and markets now known or hereafter devised. This authorization shall continue indefinitely, unless I otherwise revoke said authorization in writing. I understand and agree that these materials shall become the property of the Louisa County Sheriff's Office and will not be returned. I hereby hold harmless, and release the Louisa County Sheriff's Office from all liability, petitions, and causes of action which I, my heirs, representatives, executors, administrators, or any other persons may make while acting on my behalf or on behalf of my estate.

  9. Applicant's Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  10. If under 18 Parent / Guardian Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  11. Leave This Blank:

  12. This field is not part of the form submission.