Polk County Sheriff s Office

Polk County Sheriff s Office Explorer Post 900 Application Grady Judd, Sheriff Polk County Sheriff s Office 1891 Jim Keene Blvd Winter Haven, FL 33880 (863) 298-6200 www.polksheriff.org Pride In Service TEN STAR ACCREDITED AGENCY PCSO FORM 358 (REV 04/14/16) Page 1 of 14

Dear Applicant, Thank you for showing an interest in the Polk County Sheriff's Office Explorer Post 900. If you are accepted, you will find that Explorer Post 900 is more than just an introduction to Law Enforcement; it also promotes life skills such as Leadership, Integrity, Team Work, Education and Communication. Becoming a member of Explorer Post 900 is more than just joining a youth organization; you are entering into a Family who will be there to help you succeed! Members will have the opportunity to participate in the annual Explorer Academy which previews many of the same objectives the Recruits must study and become proficient in while in the Law Enforcement Academy at Polk State College. This academy will prepare you, as an Explorer, to participate in Ride-A-Longs with actual working deputy sheriffs out in the field. At the Sheriff s Office we place a great deal of emphasis on education. It is highly recommended that a young person attend college and obtain their degree prior to entering the Law Enforcement profession. Our Advisors work closely with the Polk County School Board to ensure that attendance and grade point averages (GPA) are maintained at an acceptable level while participating in Explorer Post 900. Within this application you will find various forms that MUST BE SIGNED AND/OR NOTARIZED. Please take the time to ensure each page is completed fully and accurately prior to submission. I sincerely hope to see you soon as a member of the Polk County Sheriff's Office Explorer Post 900. Sincerely, Sergeant Safe Schools Division School Resource Section PCSO FORM 358 (REV 04/14/16) Page 2 of 14

Requirements to Become a Member of Explorer Post 900 The Polk County Sheriff s Office Explorer Post 900 was organized to offer students an introduction into Law Enforcement as a possible career. The Explorer Post is a cadet-based program designed for students who are interested in any aspect of Law Enforcement. It allows an individual to learn about careers in Law Enforcement. This program is designed to develop self-esteem, discipline, good citizenship and leadership skills. The Explorer Post 900 also creates a better understanding between the Sheriff s Office and the youth of our community. The Explorer Post 900 is a member of the Florida Sheriff s Explorer Association and chartered by the Boy Scouts of America (BSA). In order to be accepted into Explorer Post 900 you must be able to meet the following requirements: 1. You must be a U.S. citizen and/or legal resident alien and a resident of Polk County. 2. You must maintain a minimum grade point average (GPA) of 2.0 ( C average) in school. 3. You will have completed eighth (8 th ) grade and be presently enrolled in high school. 4. You must be at least fourteen (14) years of age and under twenty (20) years of age. 5. You must have a satisfactory school record (both Academically and Disciplinary). 6. No criminal record. 7. If you are eligible to be issued a Florida Driver License, you must have a satisfactory driving record (NO MOVING VIOLATIONS/POINTS/SUSPENSIONS). 8. Be of good moral character. 9. Be able to participate in regularly scheduled meetings and/or events (this is to include, but not limited to: special training events, community events, fundraising activities and some social events). 10. Pass a background check and an oral review board, consisting of three (3) ranked Explorers and an Advisor. 11. You must include a copy of your Birth Certificate, along with a copy of any state-issued Photo Identification Card and/or School Identification Card (for background check). 12. No visible tattoos/skin branding. Please note that regular meetings are scheduled on the first (1 st ) and third (3 rd ) Mondays of each month at the pre-determined location as per the events calendar posted on www.polksheriff.org. Regular attendance to the meetings is mandatory, unless excused prior to the meeting. Transportation to and from the meetings/events is the responsibility of the Explorer. Please read and review this application and fill it out completely. Please return the application in person, or U.S. Mail to: Polk County Sheriff's Office (1891 Jim Keene Blvd., Winter Haven, FL 33880) for processing. Applicants will be notified by mail, phone or e-mail regarding the status of their application and any future appointments/interviews. PCSO FORM 358 (REV 04/14/16) Page 3 of 14

Personal Information Name: Last First MI Date of Birth: Current Address: Month Day Year Place of Birth: Street City State Zip Home Telephone # Cell Phone # E-Mail Address Is this where you receive your mail? If not, what is your mailing address? Social Security #: Driver License/I.D. Card #: Sex: Race: Height: Weight: Hair Color: Eye Color: Are you an American citizen? How long have you lived in Polk County, Florida? Parent/Guardian Information: Name Date of Birth Address E-Mail Address Home Telephone #: Cell Phone #: Employer Work Phone # Name Date of Birth Address E-Mail Address Home Telephone #: Cell Phone #: Employer Work Phone # PCSO FORM 358 (REV 04/14/16) Page 4 of 14

School, Employment and Extracurricular Information Are you in school? If so, which one? Did you graduate? Your GPA, if known: Have you ever had any type of disciplinary action taken against you while you were a student in school? If so, please describe: Are you involved in any other clubs, sports, groups, bands or organizations? If so, what? Have you ever received any Honors, Awards or Scholarships? If so, what for? Are you currently employed? If so, please provide the following: Employer s Name Telephone # of Employer Address of Employer PCSO FORM 358 (REV 04/14/16) Page 5 of 14

Criminal History Have you ever been arrested? If so, what was the Offense and Disposition? Have you ever had your name legally changed? If so, please provide all aliases: Do you go by any nicknames or street names? If so, what? Have you ever been involved in the Criminal Justice System before? Such as: Diversion Program, Teen Court, Jail Tour, Department of Juvenile Justice, Probation, Traffic Ticket/ Violations, Injunctions Has anyone in your immediate family ever been arrested? What Offense? Have you ever been a member of a Street Gang? If yes, which one and for how long were you affiliated with them? PCSO FORM 358 (REV 04/14/16) Page 6 of 14

Interest Questions Why do you want to become a member of Explorer Post 900? What is your desired career? Are you related to anyone who is or has been employed by Polk County Sheriff's Office? If so, please list them and what their position is/was in the agency: Have you ever been a member of another Explorer Post? If so, which one and reason for leaving: Have you ever received any Law Enforcement training prior to applying to this Post? If yes, please describe what, where and when: Will you be able to attend scheduled meetings and participate in Post sponsored events? If not, why? PCSO FORM 358 (REV 04/14/16) Page 7 of 14

References Below please list three (3) people NOT related to you who have known you for a minimum of two (2) years: Last Name First Name MI Relationship Telephone #: Date of Birth Years Known Home Cell Current Address Last Name First Name MI Relationship Telephone #: Date of Birth Years Known Home Cell Current Address Last Name First Name MI Relationship Telephone #: Date of Birth Years Known Home Cell Current Address PCSO FORM 358 (REV 04/14/16) Page 8 of 14

Medical/Health Information *This information is optional, but will assist the program in ensuring the safety of all involved. Please sign below ONLY if the applicant or parent/guardian refuses to complete the Medical/Health Information section of this application. Refused to Provide Information: (Signature of Applicant or Parent/Guardian, if under 18 years of age) Do you have any illness or condition that may prevent you from participating in Explorer activities? If yes, why? Do you take any medication on a regular basis? If yes, what? Please advise if you have any of the following: Eye Glasses Contact Lenses Hearing Impaired If yes, please explain: Have you ever been diagnosed with a mental, nervous disorder, or have you ever attempted or threatened suicide? If yes, please provide details: Please list any restrictions you may have for medical reasons: The information in the section is accurate to the best of my knowledge. Signature of Applicant Signature of verifying Parent/Guardian, if under 18 years of age PCSO FORM 358 (REV 04/14/16) Page 9 of 14

To Whom It May Concern: Permission for Medical Treatment I, the undersigned, being the Parent, Legal Next of Kin (NOK) or Legal Guardian of: Printed/Typed Name of Explorer Date of Birth Hereby authorize any necessary medical treatment for this person while participating at any and all Polk County Sheriff s Office Explorer Post 900 functions, to include riding along with a deputy sheriff in or out of Polk County, Florida and the United States of America. I also guarantee payment of all charges incurred during this medical treatment (physicians, x-rays, hospital, labs, medications, ambulance transport, etc.). Information: All allergies (to include food) and medications: Special medical needs/problems: Family Physician: Office Address Telephone # Insurance Company: Policy #: Printed/Typed Name of Parent, Legal NOK or Legal Guardian, address and telephone #(s): Signed before me this day of 20. Signature of Parent, Guardian, NOK: Notary Public, State of Florida: My commission expires: Identification Source: Personally Known: Produced Identification: Type of Identification: Identification Card #: PCSO FORM 358 (REV 04/14/16) Page 10 of 14

Release, Hold Harmless and Indemnification Agreement For and in consideration of being permitted to become a member of the Polk County Sheriff's Office Explorer Post 900, which is supervised by Deputy Sheriffs of the Polk County Sheriff's Office, the undersigned, as guardian or parent of the minor child listed in this document, do hereby forever release Grady Judd, as Sheriff of Polk County, Florida, individually and in his official capacity, and all of his Deputy Sheriffs, employees, appointees, agents and the County of Polk, Florida, from any and all claims, causes of action, demands or damages, present, past or future, contingent or otherwise, which may directly or indirectly arise out of, in conviction with, or by reason of membership and participation in the Explorer Post 900, provided by the Polk County Sheriff's Office, to the minor child listed. I hereby swear and affirm that I have requested the Polk County Sheriff's Office to allow the minor child listed to become a member of the Polk County Sheriff's Office Explorer 900, and do hereby acknowledge membership according to the conditions herein. As a further consideration of the acceptance of the opportunity for the minor child listed to become a member of the Explorer Post 900, being provided by the Polk County Sheriff's Office, I hereby expressly covenant and agree to indemnify, defend and to hold and save harmless Grady Judd, Sheriff of Polk County, Florida, and all of his Deputy Sheriffs, employees, appointees, agents and the County of Polk, Florida, from any and all claims, causes of actions, demands or damages, and costs (including all reasonable attorney fees) which may directly or indirectly arise out of or in connection with or by reason of any and all claims, causes of action, demands or damages, present, past or future, contingent or otherwise instituted by other person, firm or corporation in exchange for the opportunity for the minor child listed to be a member and participate in the Polk County Sheriff's Office Explorer Post 900. I, the undersigned, as parent or legal guardian, assume full responsibility for risk of bodily injury, death, or property damage due to negligence of releases or otherwise while the minor child listed is participating in any Explorer Post 900 activity. By my signature, I hereby authorize a representative of the Polk County Sheriff's Office to consent to medical treatment for the minor child listed in the event that I cannot be contacted. The foregoing representative to whom I give such authority has care and control of the child while he/she is participating in any Explorer Post 900 activity. The undersigned agrees that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the laws of the State of Florida and that if any portion of the agreement is held invalid, it is agreed that the balance shall, not withstanding, continue in full force and effect. PCSO FORM 358 (REV 04/14/16) Page 11 of 14

Release, Hold Harmless and Indemnification Agreement, Cont. Witness my signature this day of, 20. Releasing Party (Print/Type) Releasing Party s (Guardian s) Signature (if participant is under 18 years of age) State of Florida County of Polk On this day of, 20, before me personally appeared to me known to be the person who executed the foregoing instrument, and acknowledged that he/she executed the same as his/her free act and deed. Notary Public State of Florida My commission expires: Identification Source: Personally Known Produced Identification Type of Identification: Identification Card #: PCSO FORM 358 (REV 04/14/16) Page 12 of 14

Affirmation/Authorization Applicant: I,, do affirm the foregoing information is true and correct to the best of my knowledge. I further promise to represent the Polk County Sheriff's Office Explorer Post 900 in a positive manner, understanding that my actions are a reflection on the Explorer Post 900, the Polk County Sheriff's Office, and myself. Any reproach I bring on the same will be handled within the guidelines set forth in the General Orders, Explorer Post 900 By-Laws and/or any Local, State or Federal Laws. Signature of Applicant Date Explorer Post 900 is an Equal Opportunity Explorer Post and is open to everyone regardless of race, sex, creed or religion. There is a one-time membership fee of twenty dollars ($20.00) for processing. This fee is required by the Boy Scouts of America (BSA) for establishment of our membership in the BSA and its charter. Parent/Guardian: I,, being the parent/guardian of the listed applicant, do hereby give my permission and consent for him/her to participate in any and all meetings, events and activities within the Polk County Sheriff's Office Explorer Post 900. Signature of Parent/Guardian Date Background Check Release I,, Date of Birth do hereby authorize the Polk County Sheriff's Office Explorer Post 900 to have access to any records the agency may have concerning me, my school records, criminal records, driving record, juvenile criminal record and any employment records. I have also included a photo copy of my government-issued birth certificate and photo identification card with this application. Date: Signature of Applicant Signature of Parent/Guardian, if under 18 years of age PCSO FORM 358 (REV 04/14/16) Page 13 of 14

Rules of Conduct 1. Dishonesty will not be tolerated. 2 The member will, at all times, maintain an attitude that will be conducive to learning and promote a positive working environment. 3. The member will stay drug, alcohol and tobacco free at all times. 4. The member will maintain his/her uniform and all other issued equipment in a good state of repair. The member shall be neat, clean, and dressed in the proper uniform for meetings, details, activities or tour of duty. The member shall keep his/her hair well groomed and at an appropriate length. Each member shall be mindful that their personal appearance reflects on fellow members, Explorer Post 900, and the Polk County Sheriff's Office. 5. The demeanor of the member while in uniform shall reflect that of Maturity and Professionalism. 6. Attendance at the scheduled meetings is required. -Any single absence will require telephone/cellular contact within your chain of command. -If you have to be absent for more than three (3) consecutive scheduled meetings, you will be required to submit a written memorandum which is to be submitted, via chain of command, to the Explorer Post 900 Coordinator/Senior Advisor as to the nature of your absence. -Failure to comply with regular attendance could result in dismissal from the Explorer Post 900. 7. The member will maintain a minimum GPA of 2.0 ( C average) in school. If a member would like to apply and obtain a position of rank, the member will maintain a minimum GPA of 3.0 ( B average) in school. A member shall be dismissed from the program upon leaving high school without graduating. 8. The member shall maintain a positive attitude toward the law and law enforcement. 9. The member shall be punctual, alert and reliable. 10. The member shall manage any social media they may have (Facebook, Twitter, etc.) so as not to bring any humiliation or dishonor to themselves, the Explorer Post 900, or the Polk County Sheriff's Office. An Advisor may review your social media sites; anything deemed as inappropriate will first be given a warning, and any subsequent offense may result in dismissal. I hereby acknowledge that I have read and understand the preceding rules of conduct and agree to abide by them to the best of my ability. Signature of Applicant Date Signature of Witness (Parent, Guardian, NOK) Date PCSO FORM 358 (REV 04/14/16) Page 14 of 14