Palmdale Partners

Academy Application

Academy Schedule and Information

* = Required Field

Please use only letters and numbers, commas, periods or apostrophes in the form fields.
Other special characters will not be allowed.

*Name:		*Date:
*Street:
*City:	*State:	*Zip:
Mailing Address (if different):
*Home Phone:	*Work Phone:	*Cell Phone:
E-mail Address:
Confirm E-mail Address:
*Grade Completed	*College Completed
Degree(s):	Other:
Professional Memberships:
*Have you ever served on a board or commission for a local government?:		Yes No
If yes, explain/list:
The Academy will be held September 18 – November 13. Sessions will be held on Thursday evenings from 7:00 – 9:30 PM. *Will you be able to attend all 9 classes?
Yes	No, please explain
OPTIONAL: In order to ensure that we reach a cross section of our community, and for statistical purposes, please describe your:
Age:	Gender:	Ethnicity:
Do you require any special accommodations to participate in this program?
Yes, please explain No
Please list any civic, professional, business, religious, social, or other organizations of which you are a member. If new to Palmdale, you may include activities from other communities.
Organization	Years of Membership	Positions/Activities



Release/Certification I agree to attend all sessions to the best of my ability. I give City staff permission to use my image on official documents, brochures, and videos.
*Signature:		*Date:

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City of Palmdale

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Palmdale Partners

Academy Application