CITY OF BURLINGTON POLICE DEPARTMENT YOUTH POLICE ACADEMY Class II The City of Burlington Police Department is conducting its Second Youth Police Academy. This program is geared towards teenage students who are interested in a career in law enforcement. This 12 day police academy style training program is designed to expose students (between the ages of 14 an 17) to the many different aspects that can be found in the law enforcement community. While at the Academy, you will participate in a variety of activities that actual Police Recruits participate in as part of their training. Students will learn about and participate in include: Criminal & Motor Vehicle Law Criminal Investigations Firearms & Use of Force K-9 Demonstrations Physical Training Military Drill Instruction from NJSP C.P.R. For an application, please contact Ptl. B. Langford via email: youthprograms@burlingtonpolicenj.com or visit the Burlington City Police Department website. City of Burlington Police Department Youth Police Academy 525 High Street Burlington, NJ 08016 609-386-0262 PLEASE NOTE: All applicants will be required to submit a completed application prior to the start of the Academy. A brief background check will also be conducted on all applicants. CITY OF BURLINGTON POLICE DEPARTMENT YOUTH POLICE ACADEMY PROGRAM
525 HIGH STREET, BURLINGTON, NEW JERSEY 08016 JULY 13 th THROUGH JULY 24 th 2015 Chief of Police PHONE: (609) 386-0262 Anthony J. Wallace FAX: (609) 387-4253 Lead Instructor Ptl. Bennie Langford NAME OF APPLICANT RESIDENTIAL ADDRESS PHONE # SCHOOL DATE OF BIRTH GRADE GRADUATION YEAR AUTHORIZING PARENT OR GAURDIAN RELATIONSHIP TO APPLICANT CELL PHONE WORK PHONE HOME PHONE EMAIL HOW WILL YOUR CHILD ARRIVE AT ACADEMY? BUS WALK DROP OFF HOW WILL YOUR CHILD GET HOME FROM ACADEMY? BUS WALK PICK UP NAME (S), ADDRESS, AND TELEPONE NUMBERS OF PERSONS AUTHORIZED TO PICK UP CADET NAME
ADDRESS NAME ADDRESS EMERGENCY CONTACT: PLEASE LIST TWO NEIGHBORS AND/OR RELATIVES (over the age of 21) NAME ADDRESS NAME ADDRESS SIBLING(S) NAME DATE OF BIRTH NAME DATE OF BIRTH NAME DATE OF BIRTH NAME DATE OF BIRTH NAME DATE OF BIRTH CITY OF BURLINGTON POLICE DEPARTMENT YOUTH POLICE ACADEMY PROGRAM 525 HIGH STREET, BURLINGTON, NEW JERSEY 08016 JULY 13 th THROUGH JULY 24th 2015
Chief of Police PHONE: (609) 386-0262 Anthony J. Wallace FAX: (609) 387-4253 Lead Instructor Ptl. Bennie Langford I certify that the below-named student has no serious respiratory problems and is medically cleared to participate in physical training consisting of a 1 ½ mile run, push-ups, and sit ups. MEDICAL CLEARANCE Physician Signature Business Address Physician Name (Print) Telephone Number NO APPLICATION WILL BE ACCEPTED WITHOUT A COMPLETED MEDICAL CLEARANCE FORM. AN ORIGINAL PHYSICIAN S SIGNATURE IS REQUIRED. NO PHOTOCOPIES WILL BE ACCEPTED. RELEASE OF INFORMATION FOR BACKGROUND INVESTIGATION I hereby consent to the background investigation and authorize a review of all school records, or any part thereof concerning myself, by and to a duly authorized police officer of City of Burlington PD.
Including all public and private records, to include and not limited to those that may be deemed to be of a privileged or confidential nature. I understand that all information will be kept confidential. I understand that should any statement or provided information I have made, proves to be false, misleading, or erroneous, it may result in rejection of my application or dismissal from the Youth Police Academy. Have you ever been arrested, convicted or charged with any offence other than minor traffic offenses? Yes No If yes, please explain in detail to include what action was taken against you Parent/Guardian Name (Print) Parent/Guardian Signature Student Signature
NOTE: Cadets will be required to attend the academy sessions in the described uniform. Khaki pants/shorts Belt Good running shoes Shirts/Hats will be provided o Please specify shirt size: Adult - X-Large Large Medium Small X-Small AUTHORIZATION / WAIVER I hereby apply to enroll in the City of Burlington Police Department s Youth Police Academy. I have answered all questions on this application to the best of my knowledge. I understand that the City of Burlington Police Department reserves the right to reject this application based on the information provided. It is understood that City of Burlington Police Department may dismiss the cadet for inappropriate behavior at any time during the duration of Youth Police Academy program. Furthermore, City of Burlington Police Department accepts no responsibility for the loss or damage of the cadet s personal property. Moreover, in the event of a medical emergency, I give permission to City of Burlington Police Department to use their selected medical response team to administer emergency medical treatment in my absence to my child/ward; I agree to assume full liability for any injury, damage, or loss that I or my child/ward may sustain as a result of such participation. I agree to relinquish and waive all claims and hold harmless the City of Burlington, City of Burlington Police Department, it s sponsors, volunteers, and employees from any and all claims that may arise as a result of my child/ward s participation during scheduled hours in the Youth Police Academy and/or in/on the City of Burlington Police Departments property and/ or department vehicles, as well as, field trip participation and traveling. Signature of Parent/Guardian Date Mail/Fax/Personally deliver completed applications and forms, no later than July 1st 2015 City of Burlington Police Department 525 High Street Burlington, NJ 08016 Fax (609) 387-4253 Parent and Camper must attend one of the following orientation meetings to be held at July 6, 2015 If you do NOT attend an orientation, your child will be disqualified from attending the Youth Policy Academy Program.