PLEASE READ BEFORE YOU BEGIN:

2. Contact Information & Eligibility
4. First Name:*
5. Last Name:*
6. Date of Birth:*
   Date of Birth:
8. Street Address:*
10. City:*
11. State:*
12. Zip:*
14. Email:*
15. Phone Number:*
19. Questionnaire
21. Why are you interested in applying to participate in the La Habra 101 Civics Academy?
23. In your opinion, what are the three most important issues facing the City of La Habra today?
25. What would you like to learn or take away from this program?
27. Where did you hear about this program? *
    -- Select One --Social MediaFlyerWord of MouthCity WebsiteNews Article (La Habra Life newsletter, Life in La Habra magazine)City Council MeetingOther
29. Would you be interested in serving on a City Commission, such as the Planning Commission or Community Services Commission?

    1. No

    1. Yes
30. If so, which one?

    1. Planning Commission
    2. Community Services Commission
    3. I'm interested in both!
32. Use this space to provide any additional comments:
36. Do you authorize City of La Habra staff to take and share photos, which may include you, for marketing purposes? *

    1. No

    1. Yes
38. Have you applied for the La Habra 101 Civics Academy before? *

    1. No

    1. Yes
40. Certification and Authorization
42. I certify that all statements made in this application are true and complete. *

    1. Agree
44. Please type your name here to confirm submission:*
45. Date:
    Date:
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit Submit and Print

* indicates a required field