mc public safety academy application updated

7/28/2019 Mc Public Safety Academy Application Updated

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MORRIS COUNTY PUBLIC SAFETYYOUTH ACADEMY 2013

THE FOLLOWING INFORMATION IS REQUESTED OF ALL PROSPECTIVE PARTICIPANTSIN THE MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY PROGRAM. ANY FALSEOR INCOMPLETE INFORMATION COULD EXCLUDE THE APPLICANT FROMPARTICIPATING IN THIS PROGRAM.

STUDENT INFORMATION: (MUST PRINT CLEARY)

STUDEN TS NAME:

,LAST FIRST

ADDRESS:

CITY : STATE: ZIP:_

HOME PHONE: CADET CELLULAR NUMBER:

DATE OF BIRTH: / / M/F_ CADET E-MAIL:

AGE: SSN: ______________

UNITED STATES CITIZEN: Y OR N GREEN CARD Y OR N

PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN: PARENT E-MAIL:

CONTACT NUMBERS: HOME _WORK_ ___ CELLULAR NUMBER: ALTERNATE CELLULAR NUMBER:

ALTERNATE EMERGENCY CONTACT: (Other than parent information listed above):

NAME: RELATIONSHIP:

ADDRESS: TOWN:

PHONE: CELLULAR NUMBER:

INSURANCE INFORMATION:

MEDICAL INSURANCE COMPANY:

ADDRESS: _______________________

GROUP #: POLICY #:

NAME OF POLICY HOLDER: ______________________

PRIMARY CARE PHYSICIAN NUMBER #: ____________


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HIGH SCHOOL INFORMATION

NAME OF HIGH SCHOOL: ___________________________CURRENT GRADE: __

ADDRESS:

CITY: STATE: PHONE NUMBER:_

PRINCIPAL: GUIDANCE COUNSELOR:

GRADE POINT AVERAGE:

HAVE YOU EVER BEEN SUSPENDED OR EXPELLED FROM SCHOOL YES OR NO(IF YES PLEASE EXPLAIN WHEN AND REASON)

__________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ________________

ADDITIONAL INFORMATION:ON A SEPARATE SH EET OF PAPER, PLEASE AN SWER TH E F OLL OWIN G TWO QUESTI ONS. EACH ANSWER SH OUL D BE AT L EAST PAGE. ANSWERS M UST BE TYPEWRI TTEN AND ATTACH ED.

1. WHY ARE YOU APPLYING TO THE MORRIS COUNTY PUBLIC SAFETYYOUTH ACADEMY?

2. HOW WILL YOU BENEFIT FROM ATTENDING THE MORRIS COUNTYPUBLIC SAFETY YOUTH ACADEMY?

OPTIONAL INFORMATION

Gender: Male Female

Ethnic Code:

Black, Non-Hispanic American Indian/Native American or Alaskan Native

Asian or Pacific Islander (India, China, etc.) Latino/Hispanic

White, Non-Hispanic Other _____________

_______________________________________________

PARENT/GUARDIAN SIGNATURE STUDE NTS SIGNATURE

DATE:


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MEDICATIONS Please list below any prescribed medications that your child is required to take regularly. Pleaseindicate below whether or not your child will be required to take or carry the medication with him/her during the Morris County Public Safety Youth Academy. Medication must be in original prescribed

package. A certified EMT will be available during the camp for any medical emergencies.

Please be advised that the youth may be afforded the opportuni ty to parti cipate in defensive tactics,

simulated f ir earms train ing, and other outdoor activi ties. Should you wish your chil d not to parti cipate in a certain activi ty or shoul d your chi ld have any special restr ictions, please l ist below.

Name of Youth:

My Child: Does Not Take Any Prescribed Medication (If this box ischecked, you must sign the form below).

My Child Does Take Prescribed Medication (If this box is check, you mustcomplete the information below and sign the form below).

Name of Medication: ___

Medical Condition for which medication is needed: ________________________________

___________________________________________________________________________________________

Dosage/Administration (Times per day): _____

Any Special Needs/Restrictions: ______

___________________________________________________________________________________________

Parents Signature:

Date: _______________________


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THE UNDERSIGNED , HEREBY GIVES PERMISSIONPRINT NAME OF

PARENT/GUARDIAN

AND AUTHORIZATION FOR MY SON/DAUGHTER PRINT NAME OF CHILD

TO PARTICIPATE IN THE MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY AND ALLTHE ACTIVITES OUTLINED IN THE CALENDAR OF EVENTS, AS WELL ASTRANSPORTATION TO AND FROM SAID EVENTS AND THE FOLLOWING SPECIFICACTIVITIES ( Check All That A pply):

Physical Training/Exercise/Sports F.A.T.S (Firearms Training System) Military, Police, EMS, OEM and Fire Training and Demonstrations PG-13 Movie Consent for Photography/Videotaping/Interviews THE UNDERSIGNED, ON THEIR BEHALF AND ON BEHALF OF THEIR CHILD, HEREBYRELEASES, DISCHARGES AND WAIVES ANY AND ALL CLAIMS, COSTS, LAW SUITS, LIABILITY,CAUSES OF ACTION, ORDERS AND THE LIKE AGAINST THE COUNTY OF MORRIS, INCLUDINGITS EMPLOYEES, PROFESSIONALS, CONTRACTORS, AGENTS, ELECTED OFFICIALS (i.e.FREEHOLDERS, SHERIFF AND CLERK), ALL INSTRUMENTALITIES OF THE COUNTY OFMORRIS, THE MORRIS COUNTY DEPARTMENT OF LAW & PUBLIC SAFETY, AND THEIR AGENTS AND EMPLOYEES THEREOF, THAT THE UNDERSIGNED MAY HAVE FOR ANYREASON, INCLUDING BUT NOT LIMITED TO, PERSONAL INJURIES, DAMAGES OR LOSSES OFANY NATURE, WHICH MAY RESULT, OR OCCUR AS A RESULT, OF PARTICIPATION IN THISPROGRAM AND IN ANY CAPACITY OR FUNCTION AS A YOUTH ACADEMY PARTICIPANTAND/OR ANY ACTIVITY RELATED THERETO.

THE UNDERSIGNED FURTHER AGREES TO HAVE THEIR CHILD OBEY DIRECTIVES OFYOUTH ACADEMY INSTRUCTORS, POLICE OFFICERS OR THEIR DESIGNEES WHILEACCOMPANYING SAID OFFICER. ADDITIONALLY, PARTICIPATION IN THE PROGRAM CANBE RESCINDED AT ANY TIME DURING THE COURSE OF THE ACADEMY WITHOUT CAUSEAND IS IN THE SOLE AND ABSOLUTE DISCRETION OF THE POLICE INSTRUCTORS.

I HEREBY ATTEST TO HAVING READ THIS DOCUMENT AND THE CALENDAR OF EVENTSAND ACKNOWLEDGE THE UNDERSTANDING THEREOF. I UNDERSTAND ANDACKNOWLEDGE THAT MY CHILD WOULD NOT BE PERMITTED TO PARTICIPATE IN THEYOUTH ACADEMY BUT FOR MY SIGNING THIS FORM.

___________________________________ _______________________________PARENT/GUARDIAN SIGNATURE DATE


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DISMISSAL RELEASE

I grant I do not grant

my permission for my child

to be dismissed from the Morris County Public Safety Youth

Academy, held during the week of August 5 through August 9,

2013, on their own, without a parent/guardian being present at

the time of dismissal.

___________________________________ _______________________________PARENT/GUARDIAN SIGNATURE DATE


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UNIFORM SIZE SELECTION

Please circle your true size. Oversize or undersize clothing will not beacceptable and the cadet will be required to select uniforms in the closest sizeavailable.

TEE SHIRT SIZE (PLEASE CIRCLE):

(S) (M) (L) (XL) (XXL) OTHER________

GYM SHORT SIZE (PLEASE CIRCLE):

(S) (M) (L) (XL) (XXL) OTHER_________

*Please note sizing is based on mens clothing*


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RULES & REGULATIONS

1. Respect yourself and others 2. Raise your hand if you want to speak 3. When you are acknowledged, you will stand and respond with Yes Sir, No Sir, Yes

Maam, No Maam 4. Pay attention to the speaker 5. Classroom/Class trip disruption will not be tolerated 6. All participants will follow directions of all police officers and civilian instructors 7. Do not litter 8. No foul language will be tolerated 9. No horse-play allowed 10. Academy T-Shirt and Shorts are to be worn every day including the graduation

ceremony. Please wash daily! 11. Stay with your group during field trips 12. Video games, ipods, etc., are not allowed 13. No hats 14. A guardian release form is required if you are walking home or if someone other than

your parent/guardian is picking you up at the end of the day 15. No Smoking 16. No sagging short, and shirts must be tucked in 17. No Make-up 18. No Jewelry 19. Long hair must be worn up 20. You are expected to conduct yourself as a lady or gentleman at all times. Proper

decorum is demanded 21. If a cellular phone is brought to the academy, it must be turned off. There will be no

phone calls/texting while the academy is in session. If you are caught your phone will be confiscated for the remainder of the day

mc public safety academy application updated

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