MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY 2013

THE FOLLOWING INFORMATION IS REQUESTED OF ALL PROSPECTIVE PARTICIPANTS IN THE MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY PROGRAM. ANY FALSE OR INCOMPLETE INFORMATION COULD EXCLUDE THE APPLICANT FROM PARTICIPATING IN THIS PROGRAM.

STUDENT INFORMATION: (MUST PRINT CLEARY) STUDENTS NAME: ADDRESS: CITY : HOME PHONE: DATE OF BIRTH: / AGE: / STATE: ZIP:_ , LAST FIRST

CADET CELLULAR NUMBER: M/F_ CADET E-MAIL:

SSN: ______________ GREEN CARD Y OR N

UNITED STATES CITIZEN: Y OR N PARENT/GUARDIAN INFORMATION PARENT/GUARDIAN: CONTACT NUMBERS: HOME CELLULAR NUMBER:

PARENT E-MAIL: _WORK_ ___ ALTERNATE CELLULAR NUMBER:

ALTERNATE EMERGENCY CONTACT: (Other than parent information listed above): NAME: ADDRESS: PHONE: INSURANCE INFORMATION: MEDICAL INSURANCE COMPANY: ADDRESS: GROUP #: NAME OF POLICY HOLDER: PRIMARY CARE PHYSICIAN POLICY #: ______________________ NUMBER #: ____________ _______________________ CELLULAR NUMBER: RELATIONSHIP: TOWN:

MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY 2013

HIGH SCHOOL INFORMATION NAME OF HIGH SCHOOL: ___________________________CURRENT GRADE: __ ADDRESS: CITY: PRINCIPAL: 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 SHEET OF PAPER, PLEASE ANSWER THE FOLLOWING TWO QUESTIONS. EACH ANSWER SHOULD BE AT LEAST PAGE. ANSWERS MUST BE TYPEWRITTEN AND ATTACHED. 1. WHY ARE YOU APPLYING TO THE MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY? 2. HOW WILL YOU BENEFIT FROM ATTENDING THE MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY? STATE: PHONE NUMBER:_ GUIDANCE COUNSELOR:

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 STUDENTS SIGNATURE

DATE:

MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY 2013

MEDICATIONS
Please list below any prescribed medications that your child is required to take regularly. Please indicate 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 opportunity to participate in defensive tactics, simulated firearms training, and other outdoor activities. Should you wish your child not to participate in a certain activity or should your child have any special restrictions, please list below.
Name of Youth: My Child: Does Not Take Any Prescribed Medication (If this box is checked, you must sign the form below).

My Child Does Take Prescribed Medication (If this box is check, you must
complete 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: _______________________

MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY 2013

THE UNDERSIGNED
PRINT NAME OF PARENT/GUARDIAN

, HEREBY GIVES PERMISSION

AND AUTHORIZATION FOR MY SON/DAUGHTER

PRINT NAME OF CHILD

TO PARTICIPATE IN THE MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY AND ALL THE ACTIVITES OUTLINED IN THE CALENDAR OF EVENTS, AS WELL AS TRANSPORTATION TO AND FROM SAID EVENTS AND THE FOLLOWING SPECIFIC ACTIVITIES (Check All That Apply):

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, HEREBY RELEASES, DISCHARGES AND WAIVES ANY AND ALL CLAIMS, COSTS, LAW SUITS, LIABILITY, CAUSES OF ACTION, ORDERS AND THE LIKE AGAINST THE COUNTY OF MORRIS, INCLUDING ITS EMPLOYEES, PROFESSIONALS, CONTRACTORS, AGENTS, ELECTED OFFICIALS (i.e. FREEHOLDERS, SHERIFF AND CLERK), ALL INSTRUMENTALITIES OF THE COUNTY OF MORRIS, THE MORRIS COUNTY DEPARTMENT OF LAW & PUBLIC SAFETY, AND THEIR AGENTS AND EMPLOYEES THEREOF, THAT THE UNDERSIGNED MAY HAVE FOR ANY REASON, INCLUDING BUT NOT LIMITED TO, PERSONAL INJURIES, DAMAGES OR LOSSES OF ANY NATURE, WHICH MAY RESULT, OR OCCUR AS A RESULT, OF PARTICIPATION IN THIS PROGRAM AND IN ANY CAPACITY OR FUNCTION AS A YOUTH ACADEMY PARTICIPANT AND/OR ANY ACTIVITY RELATED THERETO. THE UNDERSIGNED FURTHER AGREES TO HAVE THEIR CHILD OBEY DIRECTIVES OF YOUTH ACADEMY INSTRUCTORS, POLICE OFFICERS OR THEIR DESIGNEES WHILE ACCOMPANYING SAID OFFICER. ADDITIONALLY, PARTICIPATION IN THE PROGRAM CAN BE RESCINDED AT ANY TIME DURING THE COURSE OF THE ACADEMY WITHOUT CAUSE AND IS IN THE SOLE AND ABSOLUTE DISCRETION OF THE POLICE INSTRUCTORS. I HEREBY ATTEST TO HAVING READ THIS DOCUMENT AND THE CALENDAR OF EVENTS AND ACKNOWLEDGE THE UNDERSTANDING THEREOF. I UNDERSTAND AND ACKNOWLEDGE THAT MY CHILD WOULD NOT BE PERMITTED TO PARTICIPATE IN THE YOUTH ACADEMY BUT FOR MY SIGNING THIS FORM.
___________________________________ _________________________________

PARENT/GUARDIAN SIGNATURE

DATE

MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY 2013

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

MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY 2013

UNIFORM SIZE SELECTION

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

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*

MORRIS COUNTY PUBLIC SAFETY YOUTH ACADEMY 2013

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