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2. City of Cocoa Citizens Academy Application
   The City of Cocoa is proud to offer a Citizens Academy program which will give citizens a greater insight into the various services and functions of local government. Please fill out the following information completely. This program is open to all City of Cocoa residents and business owners ONLY.
4. Application Deadline

   September 1, 2021

6. Class Schedule
   The class schedule is posted on the Citizens Academy webpage. Please make sure you are able to attend each of the sessions before applying. Each participant can be excused from one session. If a participant misses more than one session, they will be removed from the program to allow room for other applicants.
8. Program Overview and Objectives

   The City of Cocoa Citizens Academy is a 10-week program designed to inform residents and community stakeholders about the operations of city government and what is involved in delivering and maintaining services to the citizens of Cocoa. The program is designed for residents and Cocoa business owners that are 18 years and older who are interested in learning more about their local government and how they can get involved in their community. Class size is limited to the first twenty (20) Cocoa residents or business owners that apply. At the end of the program, participants should have an increased understanding of the organizational structure and operations of the various departments that impact the quality of life in the City of Cocoa. Graduates of the Citizens Academy will be prepared to have a role in the future of their neighborhoods and the City overall through government/citizen engagement.

10. First Name*
11. Last Name*
13. Address1*
15. Address2
17. City*
18. State
19. Zip*
21. Phone number:*
22. E-mail Address*
24. Sharing Contact Information*

    We will typically share a participant roster with everyone who registers for the academy. Please select if you are exempt from sharing your contact information through public records per State statute 119. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0100-0199/0119/0119.html

    1. Exempt
    2. Not Exempt
26. Cocoa Business Name: (If you are not a resident of the City of Cocoa but own a business or property in the City of Cocoa.)
28. I have reviewed the posted schedule for the upcoming Citizens Academy and will be able to attend each of the sessions.*

    1. Yes
30. Emergency Contact Information
32. Full name:*
33. Relationship:*
35. Phone number:*
37. Shirt Size:*

    Must Select One. Cotton Polo Shirts.

    1. Small
    2. Medium

    1. Large
    2. X-Large

    1. XX-Large
    2. XXX-Large
39. Briefly explain why you wish to enroll in the City of Cocoa's Citizens Academy and what you hope to gain from the experience:*
41. If you need special accommodations, please contact Samantha Senger at (321) 433-8685 or ssenger@cocoafl.org.
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field