Juvenile Justice Citizens Academy Application

First Name *

Last Name *

Street Address *

City *

Zip Code *

Day Phone # *

Evening Phone # *

Your E-mail Address *

Are you a resident of Pinellas County? *

Yes

Are you a business owner in Pinellas County? *

Yes

Occupation *

Employer *

Race/Ethnicity

Gender *

Male

Female

Date of Birth *

How did you hear about the Juvenile Justice Citizens Academy? *

Tell us a little about yourself (past employment, organizations in which you are or have been active, and special interests): *

Why do you wish to participate in the Juvenile Justice Citizens Academy? *

What do you hope to gain/learn from participation in the Juvenile Justice Citizens Academy? *

How will your participation in the Juvenile Justice Citizens Academy benefit the community? *

Contact Pinellas County JDAI Coordinator, Gina Gibbs, at 727-453-7436 for additional information. The program seeks to have participants representative of Pinellas County. If chosen, you will be expected to attend at least eight (8) of the ten (10) sessions. More information is available at http://www.pinellascounty.org/justice/JJCA.htm.

If you are a person with a disability who needs an accommodation in order to participate in this program, you are entitled, at no cost, to the provision of certain assistance. If you need assistance, contact the Pinellas County Office of Human Rights at 727-464-4062.

E-mail addresses are public records under Florida law and are not exempt from public-records requirements. If you do not want your e-mail address to be subject to being released pursuant to a public-records request, do not send electronic mail to this entity. Instead, print and submit your application by fax (727-464-8490) or by mail to:

Pinellas County Justice Coordination

Attention: Gina Gibbs

440 Court Street, 2nd Floor

Clearwater, Florida 33756