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Puyallup Police Explorer Applicant Instruction Sheet As a necessary condition of consideration for membership with the Puyallup Police Department Explorers, specific information and documents are required. Failure to provide this information will result in the removal of your application for consideration. Complete the application in black ink or typed and return it to the Puyallup Police Department Explorer Captain with the following: 9 Recent Photograph 9 Photocopy – Washington Drivers License (if applicable) 9 Photocopy – Social Security Card 9 Most recent high school/college transcripts 9 Notarized Waiver of Liability 9 Notarized Consent to Medical Care (upon acceptance) Thank you for your interest in the Puyallup Police Department Explorer Program. Page 1 of 9 ---PAGE BREAK--- Puyallup Police Explorer Application Packet Requirements 1. Applicants must be either 14 years of age and have completed the eighth grade, or between the ages of 15 and 21. 2. Parental approval must be obtained if a minor. 3. School transcripts demonstrating a 2.5 grade point average, or better must be enclosed with the application. 4. The applicant must be in good health and without physical condition(s) that will endanger them, or another member of the Police Department. 5. The applicant must be of good character and possess good moral habits. Driving records will be considered. 6. All appointees must complete the Washington State Law Enforcement Explorer Academy within the first 12 months of membership, subject to advisor approval. 7. Upon appointment to the Post, a mandatory six months probation period must be served. 8. All applicants must successfully pass a background investigation including, but not limited to, a criminal history records check. 9. None of the above requirements is intended to be an automatic disqualifier. All of the above are taken into consideration when considering an applicant. If you feel that there are special circumstances that should be considered when applying, contact the Explorer Coordinator. When filling out the attached application: • Fill in all of the blanks. If an item does not apply to you put in N/A. • Give complete information, including your first, middle, and last name spelling each name completely. • Submit information only if you are sure of its accuracy. • Be sure that you and/or your parents sign the forms in the appropriate places. • Intentional withholding of information or falsification of information on this application will result in immediate denial of acceptance. If the applicant is accepted and falsification is discovered, the Explorer will be dismissed without recourse. • Incomplete packets will not be accepted. Page 2 of 9 ---PAGE BREAK--- Puyallup Police Explorer Post #530 Application Personal Information Last Name: First Name: Middle Name: Address: City: State: Zip: Home: Cell: Work: Social Security Number: Date of Birth: MM/DD/YYYY U.S. Citizen? Yes No With whom do you reside? How long have you lived at your current address? If employed, would your employer allow you time off from work to attend emergency Explorer functions? Yes No Are you able to donate time on weekends? Yes No Are you able to donate time on evenings? Yes No Have you had any First Aid or CPR training? Yes No Are you currently certified? Yes No Expiration date: Record of Education High School attended: Zip: State: City: Did you graduate? Yes No Address: Last grade completed: G.E.D: Year: College/University attended: Zip: State: City: Did you graduate? Yes No Address: Last grade completed: Year: Page 3 of 9 ---PAGE BREAK--- Employment Record Please begin with the most recent or current employment. List all present and past employment for the last 5 (five) years. Use additional paper and attach if necessary. 1. Company Name: Address: Dates Employed: Telephone: to Immediate Supervisor: Duties: Reason for leaving: 2. Company Name: Address: Dates Employed: to Telephone: Immediate Supervisor: Duties: Reason for leaving: 3. Company Name: Address: Dates Employed: Telephone: to Immediate Supervisor: Duties: Reason for leaving: May we contact the employers listed above? If not, include by number which one(s) you do not wish us to contact and why. List any special training you have attended: Page 4 of 9 ---PAGE BREAK--- Personal History Please list the names of at least three persons not related to you who may be contacted as references. These people should know your qualifications and should be able to attest to your character, honesty and personal qualities that would make you an asset to the Puyallup Police Department Explorer Program. No more than one law enforcement reference, please. Name: Address: City: State: Zip Code: How long have you known him/her? Work Phone: Home Phone: Name: Address: City: Zip Code: State: How long have you known him/her? Home Phone: Work Phone: Name: Address: City: State: Zip Code: How long have you known him/her? Home Phone: Work Phone: Yes No Have you ever been convicted of a crime as an adult or juvenile? If yes, please list dates of all: The facts set forth in my application for the position of Puyallup Police Explorer are true and complete. I understand that if qualified for examination or accepted, false statements on this application shall be considered sufficient cause for dismissal. I further understand that I have the right to answer or provide additional information in the case of derogatory information. Signature of Applicant Date Signature of Witness Date Signature of legal guardian (if under 18) Date Signature of legal guardian (if under 18) Date Page 5 of 9 SIGN SIGN SIGN SIGN ---PAGE BREAK--- Explorer Hold Harmless and Indemnity Agreement I, the dangers that I may be exposed to while riding in a patrol vehicle and/or participating in the Explorer program. These activities include, but are not limited to: patrol vehicle ride-alongs, any traffic control, including traffic control at civic events and scenes of an emergency, dispatch procedures, correction procedures, search and rescue operations, boat patrol, firearms training, first aid and any other duties or circumstances arising out of or associated with law enforcement, the Puyallup Police Explorer Post 530 or the Puyallup Police Department. By agreeing to participate in the activities of the Puyallup Police Explorer Post 530, I hereby agree to waive any claim I may have against the City of Puyallup, its officers, employees and agents for damages for personal injury or property damage arising out of, but not limited to, the above referenced activities. I agree to this waiver whether or not the damages were caused by the sole or partial negligence and/or fault of the City of Puyallup. By agreeing to participate in the activities of the Puyallup Police Explorer Post 530, I further agree to hold harmless, indemnify and defend the City of Puyallup, its officials, employees and agents from any damages or claims of damages to be paid to, or on behalf of, myself or any other person arising out of, but not limited to, the above referenced activities whether or not the damages were caused by the sole or partial negligence and/or fault of the City of Puyallup, its employees and/or agents. Applicant Signature Date Print Name SUBSCRIBED and SWORN to before me this day of , Notary Public in and for the State of Washington, residing at Page 6 of 9 SIGN ---PAGE BREAK--- Explorer (Minor) Hold Harmless and Indemnity Agreement I/We, the parent(s) /guardian(s) of authorize my/our son/daughter to participate in the activities of the Puyallup Police Department Law Enforcement Post 530 as a Law Enforcement Explorer. I/We acknowledge the dangers that my son/daughter may be exposed to while riding in a patrol vehicle and/or participating in the Explorer program. These activities include, but are not limited to: patrol vehicle ride-alongs, any traffic control, including traffic control at civic events and scenes of an emergency, dispatch procedures, correction procedures, search and rescue operations, boat patrol, firearms training, first aid and any other duties or circumstances arising out of or associated with law enforcement, the Puyallup Police Explorer Post 530 or the Puyallup Police Department. By authorizing my son/daughter to participate in the activities of the Puyallup Police Explorer Post 530, I/we hereby agree to waive any claim I/we may have against the City of Puyallup, its officers, employees and agents for damages for personal injury or property damage arising out of, but not limited to, the above referenced activities. I/We agree to this waiver whether or not the damages were caused by the sole or partial negligence and/or fault of the City of Puyallup. By authorizing my son/daughter to participate in the activities of the Puyallup Police Explorer Post 530, I/we further agree to hold harmless, indemnify and defend the City of Puyallup, its officials, employees and agents from any damages or claims of damages to be paid to, or on behalf of, my son/daughter or any other person arising out of, but not limited to, the above referenced activities whether or not the damages were caused by the sole or partial negligence and/or fault of the City of Puyallup, its employees and/or agents. Parent/Guardian Signature Date Print Name Relationship to applicant Parent/Guardian Signature Date Print Name Relationship to applicant being duly sworn on oath, states that he/she is the parent/guardian of the above named child, that he/she has read the above authorization and waiver, and that he/she agrees to its terms. SUBSCRIBED and SWORN to before me this day of , Notary Public in and for the State of Washington, residing at Page 7 of 9 SIGN SIGN ---PAGE BREAK--- Authority to Release Information To Whom It May Concern: I hereby authorize the Puyallup Police Department or its designated agent bearing this release or copy thereof, within one year of its date, to obtain information in your files pertaining to my complete criminal and/or juvenile offense history, employment, military, credit or educational records including, but not limited to, academic, achievement, attendance, athletic, personal history and disciplinary records and criminal records including any juvenile offenses. I hereby direct you to release such information upon request of the bearer. This release is executed with full knowledge and understanding that the information is for official use by the Puyallup Police Department. Consent is granted for the Puyallup Police Department to furnish such information, as is described above, to third parties in the course of fulfilling its official responsibilities. I hereby release you as the custodian of such records and any school, college, university or other educational institution, consumer reporting agency or retail business establishment, including its officers, employees or related personnel both individually and collectively from any and all liability for damages of whatever kind, which may at any time result to me, my heirs, family or associates because of compliance with this authorization and request to release information or any attempt to comply with it. I am furnishing my Social Security Number on a voluntary basis with the understanding that such is not required by City statute or regulation. I have been advised the Puyallup Police Department will utilize this number only to facilitate the location of employment, military, credit and educational records concerning me in connection with this application. Should there be any questions as to the validity of this release, you may contact me as indicated below. Full Name: Signature: Social Security Number: Parent/Guardian (if required): Parent/Guardian (if required): Date: Current Address: Home Number: Witness: Page 8 of 9 SIGN ---PAGE BREAK--- Parental Consent for Emergency Medical Care This is to certify that any Puyallup Police Officer has my permission to authorize emergency medical care for my son/daughter by the attending physician or others he/she may choose. I accept financial responsibility for necessary treatment and services. Youth’s Name: Last First Middle Date of Birth: Last Tetanus Shot: Existing medical problems: Allergies: Family Physician: Parents can usually be reached at: Father: Mother: Parent/Guardian Signature Date Print Name Relationship to applicant SSN Parent/Guardian Signature Date Print Name Relationship to applicant SSN Home Address City State Zip Code Home Phone: Work Phone: Insurance Company Group Number being duly sworn on oath, states that he/she is the parent/guardian of the above named child, that he/she has read the above authorization and waiver, and that he/she agrees to its terms. SUBSCRIBED and SWORN to before me this day of , Notary Public in and for the State of Washington, residing at Page 9 of 9 SIGN SIGN ---PAGE BREAK--- Yes No Have you ever been stopped or questioned by law enforcement? If yes, please give circumstances: Yes No Have you ever been arrested? If yes, please explain: Yes No Do you have a valid Washington Drivers License? License Yes No Has your license ever been suspended or revoked? If yes, please explain: Yes No Have you ever been involved in a traffic collision? If yes, please explain: List all your traffic tickets: (use the back if necessary) Date Violation Issuing agency Yes No Have you ever used illegal drugs? If yes, please explain: Yes No Have you ever stolen from school or an employer? If yes, please explain: Post Acceptance Supplemental Form Personal History Page 1 of 2 ---PAGE BREAK--- The facts set forth in my supplemental questionaire for the position of Puyallup Police Explorer are true and complete. I understand that if qualified for examination or accepted, false statements on this from shall be considered sufficient cause for dismissal. I further understand that I have the right to answer or provide additional information in the case of derogatory information. Signature of Applicant Date Signature of Witness Date Signature of legal guardian (if under 18) Date Signature of legal guardian (if under 18) Date Medical History Police Explorer work involves the ability to act under stress, run, jump or do emergency lifting and carrying. Are you able to perform these essential functions with or without reasonable accommodation? Yes No If yes, please list: List all major illnesses and operations: Yes No Do you wear corrective lenses? If yes, what is your corrective vision? Demographic Information Providing this information is entirely voluntary. This information will be kept confidential, and in no way will affect your current or future volunteer opportunities with the City of Puyallup. Gender: Male Female Height: Weight: Eyes: Race: White Black Asian/Pacific Islander Hair: American Indian/Alaskan Native Unknown Page 2 of 2