Last Name

First Name

MI

Preferred Name
(for name tag/tent)

Officer/Deputy Corporal Detective Sergeant Lieutenant Captain Major Deputy Chief/Chief Deputy Assistant Chief Chief Sheriff Tele-Communicator Telecommunications Manager Retired Other
Rank
      if other:

Officer Tele-communicator Spouse Other
Title
      if other:

PID#

Date Of Birth

() -
Participant Phone

Participant Email

Small Medium Large 1X Large 2X Large 3X Large
Shirt Size

Gender:     Female     Male

Please inform us of any food allergies:

Education:
    Less than AA or 60 hours
    AA or over 60 hours
    Bachelor's degree
    Master's degree
    Terminal degree

Ethnicity:
    Black
    Indian
    Hispanic
    Asian
    White / Anglo

If attending with a spouse please provide their name here:

Will you need lodging provided?   Yes     No

What is the best time to contact you by phone?   Morning     Evening     Night

Please provide the date and a brief description of the critical incident in which you were involved.
(example: fatal shooting, incident with death of children, line of duty death of co-worker, etc.)

Agency / Department

() -
Agency Phone

Admin Email

Mailing Address

City

AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
State

Zip

Anderson Andrews Angelina Aransas Archer Armstrong Atascosa Austin Bailey Bandera Bastrop Baylor Bee Bell Bexar Blanco Borden Bosque Bowie Brazoria Brazos Brewster Briscoe Brooks Brown Burleson Burnet Caldwell Calhoun Callahan Cameron Camp Carson Cass Castro Chambers Cherokee Childress Clay Cochran Coke Coleman Collin Collingsworth Colorado Comal Comanche Concho Cooke Coryell Cottle Crane Crockett Crosby Culberson Dallam Dallas Dawson Deaf Smith Delta Denton DeWitt Dickens Dimmit Donley Duval Eastland Ector Edwards El Paso Ellis Erath Falls Fannin Fayette Fisher Floyd Foard Fort Bend Franklin Freestone Frio Gaines Galveston Garza Gillespie Glasscock Goliad Gonzales Gray Grayson Gregg Grimes Guadalupe Hale Hall Hamilton Hansford Hardeman Hardin Harris Harrison Hartley Haskell Hays Hemphill Henderson Hidalgo Hill Hockley Hood Hopkins Houston Howard Hudspeth Hunt Hutchinson Irion Jack Jackson Jasper Jeff Davis Jefferson Jim Hogg Jim Wells Johnson Jones Karnes Kaufman Kendall Kenedy Kent Kerr Kimble King Kinney Kleberg Knox La Salle Lamar Lamb Lampasas Lavaca Lee Leon Liberty Limestone Lipscomb Live Oak Llano Loving Lubbock Lynn Madison Marion Martin Mason Matagorda Maverick McCulloch McLennan McMullen Medina Menard Midland Milam Mills Mitchell Montague Montgomery Moore Morris Motley Nacogdoches Navarro Newton Nolan Nueces Ochiltree Oldham Orange Palo Pinto Panola Parker Parmer Pecos Polk Potter Presidio Rains Randall Reagan Real Red River Reeves Refugio Roberts Robertson Rockwall Runnels Rusk Sabine San Augustine San Jacinto San Patricio San Saba Schleicher Scurry Shackelford Shelby Sherman Smith Somervell Starr Stephens Sterling Stonewall Sutton Swisher Tarrant Taylor Terrell Terry Throckmorton Titus Tom Green Travis Trinity Tyler Upshur Upton Uvalde Val Verde Van Zandt Victoria Walker Waller Ward Washington Webb Wharton Wheeler Wichita Wilbarger Willacy Williamson Wilson Winkler Wise Wood Yoakum Young Zapata Zavala Other
County

Precinct

#FT Officers in Department

Please inform the Program Coordinator prior to the date of the program if you will not be attending.

I have read and agree to the above policies.