Lompoc Police Department Explorer Post #700 APPPPLIICATIION FOR MEMBERSSHIIPP Print legibly all information required and answer all questions as completely and truthfully as possible. After filling out all information, sign your full name in the space provided. By signing this application, you acknowledge that the information is correct and truthful and you give your full permission for the Lompoc Police Department and Adult Staff Members of the Law Enforcement Explorer Program to conduct a full background investigation. Any required information that is found to be false, misleading, or recklessly omitted may be grounds for rejection of this application for membership. Name: First Middle Last Current Home Address: Number Street City State Zip Former Address: Number Street City State Zip Email Address: Home Phone #: ( ) - Cell Phone #: ( ) - Date of Birth: Month Day Year Social Security #: - - Sex: Age: Height: Weight: Hair: Eyes: Driver s License #: State Number School Attending: Name Grade (Administrative Only) Int Date Advisor Approval Int Date Committee Chairman Approval Int Date Background Check Int Date NCIC / CLETS Int Date Post 700 Approval Int Date Registration / Fees Submitted Int Date Indemnity Release Signed Int Date Uniform Policy Signed Int Date Application Forwarded to Advisor Int Date Boy Scout Application Sent to Advisor 1 P a g e
I understand that by potentially joining the Lompoc Police Department Explorer Program, I am making a commitment towards a career in Law Enforcement, and that any future illegal or unethical activities will be looked down upon more severely by potential future employers based on the career path I have decided to begin. In understand that any false, misleading, or recklessly omitted information provided on this application will be grounds for immediate grounds for rejection of the applicant or dismissal from the post. I understand that by joining the Lompoc Police Department Explorer Program, there is an annual membership due of $25.00. FAMILY INFORMATION Father s Name: Date of Birth: Name of Employer: Occupation Title: Address: Telephone: Mother s Name: Date of Birth: Name of Employer: Occupation Title: Address: Telephone: Sibling s Name: Date of Birth: Sibling s Name: Date of Birth: Sibling s Name: Date of Birth: Sibling s Name: Date of Birth: Sibling s Name: Date of Birth: Are you related to any active or retired members of the Lompoc Police Department? If Yes, Please list their name and relation to you: 2 P a g e
Employment History Please list your current employers information (if any) : Business Name Supervisor Phone Number Please list your previous employment information (if any): Business Name Supervisor Phone Number Reason Employment Ended: Business Name Supervisor Phone Number Reason Employment Ended: Business Name Supervisor Phone Number Reason Employment Ended: Please list all clubs, organizations, and associations you now actively participate in or have ever participated in: Transportation Information / Traffic History Do you have reliable access to transportation to post functions and details to use when ever your presence is requested? Have you ever been pulled over by the police while operating a motor vehicle? Have you ever received a traffic ticket for a violation of a traffic law? Have you ever received a traffic ticket for an auto accident crash or traffic accident? Yes: No: 3 P a g e
Criminal / Juvenile History For applicants over 18 years of age: Please understand that even know your juvenile history is sealed and has no bearing on you as an adult, we still retain and utilize all juvenile information resulting from criminal and traffic history for law enforcement purposes. These questions below refer to BOTH JUVENILE AND ADULT HISTORY and we request information even if the offense happened before you became an adult. Past criminal activity may require you to fill our a supplement to this application to explain your situation in greater detail. Have you ever been charged with any criminal offense or received a minor misdemeanor citation other than traffic related? Explain: Have you ever been taken to a city or county juvenile bureau for questioning? Explain: Have you ever been, or are you now, on any type of juvenile or adult probation? Explain: Have you even been physically arrested and taken to any jail, juvenile detention center, police department, or released to your parents by any law enforcement agent? Explain: Have you ever consumed any alcoholic beverage that was not given to you by a parent or guardian and consumed in the presence of the same parent or guardian? Explain: Have you ever experimented or do you actively participate in any form huffing, or inhaling of harmful contaminates including but not limited to: paints, glues, sprays, or other household products? Explain: Have you ever used, abused, or taken any controlled substance or drug, either illegal in nature or not specifically prescribed to you for current medical reasons? Explain: 4 P a g e
Personal Reference Information As an applicant for the Lompoc Police s Explorer Program I understand that I am requested to submit no less that three letters of recommendations to accompany my application. All of the personal references must be at least 18 years of age, and in no way can be related to you. We suggest that you request a letter from a (1) school teacher or administrator; (2) an employer or leader of an extra-curricular group you are currently involved with or have previously been involved with; and finally (3) a family friend or a member of the Lompoc Police Department if one is personally known. Please list the references below and attach the letters to the application: Name Address Phone # Length of Relationship Name Address Phone # Length of Relationship Name Address Phone # Length of Relationship Miscellaneous Information Do you understand that should you be accepted into the program you MUST attend all regularly scheduled meetings? Do you understand that there will be classroom work and assignments given on days other then regular meeting nights? Do you understand that you will be given tests and you MUST maintain a satisfactory or higher average to remain in the program? Do you understand that you MUST maintain a passing GPA in all high school courses to remain in the program, and that you MUST present current report cards as requested by post officers? Do you understand that you are responsible for acquiring certain items of the post uniform at your own expense? Do you understand that you will be charged criminally, if at the termination of your membership from the program you fail to return any and all property issued or owned by the Explorer Program or the Lompoc Police Department? 5 P a g e
Have you discussed the Law Enforcement Explorer Program with your parents and family, and they understand the implied danger of potential incidents resulting from involvement in ride-alongs with officers or participation in uniformed functions of the program? Do you and your parents understand that before you are permitted to ride-along with any member of the Lompoc Police Department, you must satisfactorily pass a number of classes, a written examination, and be subject to the Post Advisor s acceptance for involvement in the ride-along program? Are your parents aware of the expenses involved for the uniform and equipment? Do you understand that while in uniform or present at any Lompoc Police function, there will be a strictly set of enforced code of conducts, and general provision including but not limited to : grooming and a dress code? Do you understand that membership into the Law Enforcement Explorer Program will not earn you any high school or college credit? Have you ever been a member of any other Explorer Program, applied for membership, or attended any of their events, meetings or trainings and given the impression that you may consider membership? Yes: No: If Yes, Please explain in detail: You are hereby requested to sign your full name in the space provided. By signing this application, you acknowledge that the information is correct and truthful and give your full permission for the Lompoc Police Department and Adult Staff Members of the Law Enforcement Explorer Program to conduct a full background investigation. Any required information that is found to be false, misleading, or recklessly omitted may be grounds for rejection of this application for membership. Printed Name Signature Date 6 P a g e
Please explain in detail why you want to be a member of the Lompoc Police Department Explorer Program: (attach additional pages if needed) 7 P a g e
UNIFORM POLICY I understand that upon acceptance into the Explorer program and Lompoc Police Explorer Post #700, I will be issued a uniform to use during my tenure as a member of the post. Along with being issued a uniform, a deposit as set forth in the Explorer manual will still apply. I will also be expected to care for and maintain the uniform that is issued to me, along with the purchase of certain uniform accessories for which the post does not supply. I understand that upon resignation from the post or termination from the post, the uniform shall be returned immediately and the deposit refunded. I also understand that if the uniform is not returned within 30 days, that I will forfeit the uniform deposit and that criminal charges can and will be signed. By signing below, I acknowledge that I have read the above and accept these terms. PRINT NAME: SIGNATURE: DATE: ADVISOR: DATE: If under 18 years old, a parent must sign below: PRINT NAME: SIGNATURE: DATE: 8 P a g e
To Law Enforcement Explorer Advisor: Applicant s Acknowledgement I have discussed the entire Law Enforcement Explorer Program with my parents and/or family. I understand that I will be instructed in all aspects of law enforcement and will also be instructed in the proper use of firearms and will be given the opportunity to fire weapons on a firing range under proper supervision. I am aware I will be required to attend regular meetings, training sessions, and from time to time will be required to attend special functions. I fully understand that should I leave the Law Enforcement Explorer Program for any reason, that the entire departmentally issued portion of the uniform is the sole property of the Lompoc Police Department Explorer Post #700. In understand that the Law Enforcement Explorer Program is an independent organization and is in now way connected with any school and will not earn me any type of school credit. I also agree to appear at a designated location with my parent(s) for the purpose of an interview with the Post Advisor or other Adult Staff Members of the Law Enforcement Explorer Program, if necessary. Applicant Signature: Print Name: Mother s Signature: (if applicant is under 18 years old) Print Name: Father s Signature: (if applicant is under 18 years old) Print Name: 9 P a g e
LAW ENFORCEMENT EXPLORER RELEASE AND INDEMNITY AGREEMENT (MINOR) I, residing at, being the legal parent or guardian of, who is my, and is years of age, date of birth _ / _ / _, Social Security - -, does hereby have my permission to participate in the Lompoc Police Department s Explorer Program, Lompoc,CA, permitting him/her to ride in a police vehicle and/or perform other duties within the Lompoc Police Department, in conjunction with the Lompoc Police Department s Explorer Program, do fully and forever, acquit and discharge said Lompoc Police Department, and its agents and servants, from all damages (known and unknown) and personal injuries to him/her arising out of riding in any Police vehicle(s) or performing other Explorer duties. I do, hereby, for myself, my heirs, executors, administrators, successors, and assigns, and those of stated minor, covenant with said releases to indemnify and save harmless the said Lompoc Police Department, from all claims and demands for damages, cost, loss of services, expenses or compensation on account of, or in any way growing out of any accident or incident, or its result both to person or property. In addition, I/We expressly waive all rights we may have under California Code of Civil Procedure Section 376, which provides for a parent s cause of action for injury to his/her child. SIGNATURE (Parent or Guardian) DATE PRINT NAME Witness my hand and seal this day of,. POLICE NOTARY 10 P a g e
LAW ENFORCEMENT EXPLORER RELEASE AND INDEMNITY AGREEMENT (ADULT) I, residing at, date of birth / /, being of full age and in consideration of the Lompoc Police Department permitting me to ride in a police vehicle and/or perform other duties within the Lompoc Police Department of the County of Santa Barbara, State of CA, in conjunction with the Lompoc Police s Explorer Program, do fully and forever, acquit and discharge said Lompoc Police Department, its agents and servants, from all damages (known and unknown) and personal injuries to me arising out of riding in any Police s vehicle or performing other Explorer duties. I do, hereby, for myself, my heirs, executors, administrators, successors, and assigns, covenant with said releases to indemnify and save harmless the said Lompoc Police Department, from all claims and demands for damages, cost, loss of services, expenses or compensation on account of, or in any way growing out of any accident or incident, or its result both to person or property. SIGNATURE DATE PRINT NAME Witness my hand and seal this day of,. POLICE NOTARY 11 P a g e
MANDATORY HEALTH AND IDENTIFICATION FORMS (Explorer) - IT IS THE INDIVIDUAL EXPLORER'S DUTY TO RESUBMIT THIS FORM BETWEEN YEARLY REVIEWS IF ANY INFORMATION IS CHANGED OR UPDATED NAME : DOB : / / SOC # : - - DL : STATE : EXPR : ADDRESS : CITY : ST : ZIP : HOME # : ( ) - CELL # : ( ) - OTHER # : ( ) - EMAIL : EMERGENCY CONTACTS : MOTHER'S NAME : ADDRESS : HOME # : ( ) - CELL # : ( ) - OTHER # : ( ) - FATHER'S NAME : ADDRESS : HOME # : ( ) - CELL # : ( ) - OTHER # : ( ) - OTHER CONTACT : ADDRESS : HOME # : ( ) - CELL # : ( ) - OTHER # : ( ) - 12 P a g e
MEDICAL INFO : PRIMARY CARE DOCTOR : OFFICE # : ( ) - ADDRESS : INSURANCE COMPANY : POLICY # : MEMBER # : GROUP # : POLICY HOLDER NAME : PH # : ( ) - FAX # : ( ) - BILLING ADDRESS : LOCAL HOSPITAL/S OF PREFERENCE : KNOWN ALLERGIES : MEDICAL ISSUES / HISTORY THAT EMERGENCY PERSONNEL SHOULD BE AWARE OF : 13 P a g e
MEDICAL RELEASE FORM To the Post Advisor/Lompoc Police Department Explorer Post #700: If during the course of my son s/daughter s activities with the Lompoc Police Department Explorer Post, he/she should become ill or sustain an injury, I hereby authorize the adult in charge to obtain emergency medical care for him/her. Signed: -Parent or Guardian_ Date: Explorer s Name: I DO NOT authorize emergency medical care for my son/daughter. Below is the action that I want taken, should an emergency arise: Signed: -Parent or Guardian_ Date: Explorer s Name: I also hereby acknowledge that this authorization remains in effect such as long as my son/daughter is involved in the Lompoc Police Department Explorer Post #700. Signed: -Parent or Guardian_ Date: 14 P a g e
Use of Criminal Justice & Department of Motor Vehicles Information As an Explorer of the Lompoc Police Department, you may have access to confidential criminal record information which is controlled by statue. Misuse of such information may adversely affect the individual s civil rights and violate the law. Penal Code Sections 11105 and 13300 identify who has access to criminal history information and under what circumstances it may be released. Penal Code Sections 11140-11144 and 13303-13305 prescribe the felony penalties for misuse of public records and CLETS information. Penal Code Sections 11142-13303 state: Any person authorized by law to receive a record or information obtained from a record who knowingly furnishes the record or information to a person not authorized by law to receive the record or information is guilty of a misdemeanor. Also, if an individual has lawful access to a computer system but makes unlawful inquires to any database, he or she is in violation of Penal Code Section 502. Any person who obtains information described in the subsections of 502 PC is guilty of a public offense and may be punished as a misdemeanor or a felony. Any employee, including Explorers, who is responsible for such misuse is subject to immediate dismissal. Violations of this law may also result in criminal and/or civil action. In addition, the information and services provided to law enforcement by the Department of Motor Vehicles (DMV) through the California Law Enforcement Telecommunications System (CLETS) is intended for the Department s use only in the enforcement of the law. Such information is not to be relayed to any unauthorized second parties, including the licensee himself/herself. The only authorized recipients of such information are Courts, District Attorneys and other enforcement agencies. I have read the above and understand the policy regarding misuse of criminal record information. SIGNATURE: DATE: PRINT NAME: LPD Form 395 15 P a g e
Explorer Ride-Along Hold Harmless Release I (Explorer) will be participating in a ride along during my tenure with the Lompoc Police Department Explorer s Program. This release will expire one year after the date on the bottom of this form and will need to be updated annually and/or if expired before the ride along. I am currently a member of the Lompoc Police Department s Explorer Program in good standing, certified to participate in the ride along program, and am properly covered under the insurance of the Boy Scouts of America and also my own personal carrier. I understand any medical expenses will be covered under the previous mentioned and not the responsibility of the Lompoc Police Department. During the ride along, I understand I must comply with all directions of the supervising officer that I am assigned to. I also understand that I will be required to follow all the policies and procedures set forth by the Lompoc Police Department. This includes but is not limited to : Use of Force, Vehicle Operations and Uniform Standards. I understand that I am strictly an observer and am not required to intervene directly in defense of others or in the preservation of life to the general public. I am required to act indirectly and appropriately in dangerous and life saving situations. This includes but is not limited to : observation from a point of safety & proper and informative radio communications. I understand the Lompoc Police Department cannot be held liable for any and all equipment, issued or not issued by the Explorer Program. This includes but is not limited to: Ballistic Vests, Flashlights, and Leather Duty Equipment. I understand that both the Lompoc Police Department and Boy Scouts prohibit me from carrying defensive and offensive weapons, but I am authorized to defend my own life in conjunction with appropriate Use of Force. I understand the reality of police work and the danger of personal injury and/or death, and I fully accept the risks and responsibilities of this voluntary assignment. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I will be participating in a ride along with being of full age and in consideration of the Lompoc Police Department permitting me to ride in a police vehicle and/or perform other duties within the Lompoc Police Department, in conjunction with the Lompoc Police Department s Explorer Program, do fully and forever, acquit and discharge said Lompoc Police Department, and its agents and servants, from all damages (known and unknown) and personal injuries to me arising out of riding in any Police s vehicle or performing other Explorer duties. I do, hereby, for myself, my heirs, executors, administrators, successors, and assigns, covenant with said releases to indemnify and save harmless the said Lompoc Police Department, from all claims and demands for damages, cost, loss of services, expenses or compensation on account of, or in any way growing out of any accident or incident, or its result both to person or property. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I am an adult of sound judgment and mind and I have read and understand the above document and understand that I accept this assignment voluntarily and hold the Lompoc Police Department harmless and without liability for my own decision to participate in a ride along. I am a juvenile and I have discussed and made my parents and/or legal guardians aware that I will be participating in a ride along. I have reviewed this document with them and they understand that by allowing me to accept this assignment voluntarily they will hold the Lompoc Police Department harmless and without liability for our decision for me to participate in a ride along. I have been given full consent and approval by my parents and/or guardians to participate in the ride along. - - - - Explorer Signature Date Legal Guardian / Parent Date - - - - Explorer Advisor Date Explorer Advisor Date 16 P a g e