Holly
Springs Police Explorers Application
Holly
Springs Police Explorers ApplicationName:
__________________________________________________________________________
Last
First
Middle
Address:
_________________________________________________________________________
Number & Street
_______________________________________________________________________________
City
State
Zip
Date of Birth: ____________________ Age: _____
Month/ Day/ Year
Name:
__________________________________________________________________________
Last
First
Middle
Relationship: ______________________________________________________________________
Home: ___________________________________________________________________________
Work & Cell:
_____________________________________________________________________
Name:
___________________________________________________________________________
Last
First
Middle
Relationship: _______________________________________________________________________
Home: ___________________________________________________________________________
Work & Cell: ______________________________________________________________________
Physician's Name: ___________________________________________________________________
Physician's #: ______________________ Hospital in Emergency:______________________________
School: ___________________________________________________ Grade:__________________
Work: __________________________________________ Work #:___________________________
Clubs & Organizations: _______________________________________________________________
How did you learn about Explorers: ______________________________________________________
Have you planned a career? If so what? __________________________________________________
What do you want to achieve, by being an Explorer?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
What are your interests?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
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Application Process:
___________________________________________________________________________________________________________________________
1. Return Application to Officer Couey
2. Two letters of reference (from someone not related to you)
3. Copy of your last grades (does not apply if you have graduated)
___________________________________________________________________________________________________________________________
I/We know of no health or fitness restriction that precludes the
participation of Explorer ___________________ in the
Explorer Ride-Along program for Explorer Post 1906, sponsored by the Holly
Springs Police Department.
In the event of serious illness or injury to
_________________________ while involved in this activity, I/We consent to
emergency medical treatment, x-ray examination, anesthesia, medical or surgical
diagnostic procedures or treatment that is
considered necessary in the best judgment of the emergency medical
technician/paramedic and the attending physician, and
is performed under the supervision of a member of the medical stall of the
hospital furnishing the medical services.
It is understood that in the event of a serious illness or injury, reasonable effects to reach me/us will be attempted.
Parent(s)/Guardian(s) Name: __________________________________________
__________________________________________
Parent(s)/Guardian(s) Signature: __________________________________________
__________________________________________
Home (___) __________ Work (___) __________ Message/Pager (___) __________
Notary Public ______________________________ Date ______________________
Advisor Approval ___________________________ Date ______________________
Expiration Date _____________________________
The undersigned, parents or guardians of
________________________, a participant of ____________________,
Post No. 1906, herby indemnifies and holds harmless the __________________, its
agencies and employees, specfically
including any and all police officers or personnel involved with the supervision
and control of the Holly Springs Police Explorer
Post No. 1906 from any claims of any kind whatsoever or of any nature for injury
to the person or damage to the property of
____________________, his/her parents, siblings, or heirs. This indemnity and
hold-harmless agreement shall be considered
a complete and total waiver of any and all liability on the part of the
township/city of _______________________________,
its servants, agents, or employees and particularly the police officers engaged
in the supervision and control as set forth herein above.
_______________________________________________________
_____________________________________
Explorer's Signature
Date
_______________________________________________________
_____________________________________
Parent's Signature
Date
(Explorer under 18 years of age)