Fall 2024 Cohort Positive Law Enforcement Interaction Training Program Application Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country How did you learn about the program? * Are you a United States citizen? * Yes No What is your role in the community? * Community Activist/Advocate Educator Clergy Student Other Are you seeking a career in law enforcement? * Yes No If yes, what agency? Houston Police Department Harris County Sheriff Office Federal Agency Other Have you ever been convicted of a Class B misdemeanor or higher? * Yes No If yes, are you seeking to have your record expunged? Yes No What is your race? * African American / Black Alaska Natice American Indian Asian Hispanic or Latino Native Hawaiian or Other Pacific Islander White I Choose Not to Self Identify What is your highest level of education completed? * Some high school, no diploma High school diploma Some college, no degree Vocational training certification Associate's Degree Bachelor's Degree Master's Degree Doctorate Degree Are you a Texas Southern University student? * Yes No Major / Minor Projected Graduation Date Month/Year If you are not a Texas Southern University student, would you like to receive enrollment information? Yes No Did you or do you currently serve in the military? * Yes No If yes, which branch of military do or did you serve? Are you interested in participating in a police ride along program? * Yes No What is your T-shirt size? * Small Medium Large X Large XX Large XXX Large Please list any dietary restrictions I affirm that I have completed the questions here within this application truthfully and to the best of my knowledge. * Any false or misleading information here within this application may lead to dismissal from the training program. I affirm the above. By participating in this program, you acknowledge that photos, videos, and other forms of media may be taken during the event. These images and recordings may be used by BLEA for promotional, educational, and other purposes related to the mission and activities of the organization. * I consent I do not consent Today's Date * MM DD YYYY Thank you!
