WASHINGTON LAW ENFORCEMENT EXPLORER ACADEMY

WASHINGTON LAW ENFORCEMENT EXPLORING ADVISORS ACADEMY APPLICATION

MAIL APPLICATION TO:	BASIC	Live In
W.L.E.E.A.	ADVANCED
C/O Rod Sniffen	ACADEMY PD	Commuting
3002 Wetmore Avenue	EAA
Everett, WA 98201

NAME: _____________________________________________________________________________________________

Last First Middle

ADDRESS:___________________________________________________________________________________________

Street Address

_____________________________________________________________________________________________________

City State Zip

PHONE: __(_____)________________________________ __(_____)________________________________

Home Message

SPONSORING DEPARTMENT:________________________________________________________________________

POST #: ________________________________ DEPARTMENT PHONE #: (_____)______________________________

ADVISOR ____________________________________________HOME PHONE #: (______)_______________________

Name

PERSONAL INFORMATION

Date of Birth _____/_____/_____ Last school grade completed ______ Sex ________

EMERGENCYNOTIFICATION:_________________________________________________ _________________________

Name Phone #

T-shirt Size: Small _____ Medium _____ Large _____ X Large _____ XX Large ______

FOR ADVISOR ONLY

Is Explorer currently a member of BSA? Yes _______ No _______

Is BSA application on file at Council offices: Yes _______ No _______

FOR ACADEMY USE ONLY

Accept ________ Reject ________

PERSONAL / MEDICAL / PARENTAL / INFORMATION

LIST ALL INJURIES AND SERIOUS ILLNESSES YOU HAVE HAD IN THE PAST TWO YEARS (INCLUDE DATES):

_____________________________________________________________________________________________________

LIST ALL SURGERIES YOU HAVE HAD IN THE PAST TWO YEARS:

_____________________________________________________________________________________________________

DO YOU CURRENTLY HAVE ANY PHYSICAL OR EMOTIONAL CIRCUMSTANCES THE ACADEMY STAFF SHOULD BE AWARE OF ?

_____________________________________________________________________________________________________

ARE YOU CURRENTLY TAKING ANY MEDICATION? YES ___________ NO ___________

(List Medication) (How often Taken)

_____________________________________________________________________________________________________

FAMILY PHYSICIAN __________________________________________________________________________________

Name Phone #

MEDICAL INSURANCE INFORMATION

Name of Family Medical Insurance:________________________________________________________________________

_____________________________________________________________________________________________________

Address City State ZIP

_____________________________________________________________________________________________________

Policy # Subscriber #

(Insurance information must be completed)

Does your Post carry insurance through WLEEA? Yes ________ No ________

All personal medical insurance will be primary coverage and WLEEA OR BSA coverage will be secondary.)

PARENTAL INFORMATION

PARENTS OR GUARDIAN:_________________________________________________________ ____________________

Name Phone #

_____________________________________________________________________________________________________

Address City State Zip

W.L.E.E.A. MEDICAL TREATMENT & RELEASE OF LIABILITY FORM

I, _________________________________________________(Parent or Guardian / Self),give my permission to

have my dependent/self, (full name)________________________________________________________________

Date of Birth___________Address_________________________________________________________________

City _____________________________ State_________ Zip ___________ Phone #_________________________

treated at the most available medical facility, in the event said dependent becomes ill or injured. I further understand the WLEEA Academy is usually held on a military installation and treatment is often obtained at an off-post facility. I understand I am responsible for the cost of any such treatment.

As the parent/guardian or Explorer adult over 18 (self), I authorize my son / daughter / self to participate in the activities of the W.L.E.E.A. (Washington Law Enforcement Exploring Advisors) Academy as an Academy student. This authorization acknowledges certain dangers may occur, including, but not limited to, the hazards of strenuous physical exercises, mock scene participation, firearms training and any other duty or circumstances associated with the Washington Law Enforcement Exploring Advisors Academy.

In consideration of, and by authorization of, my son/daughter/self the right to participate in such an Academy or other activities and the services, training and food arrangements for my son/daughter/self by the Washington Association of Sheriffs and Police Chiefs, WLEEA Committee, the Military Agency which assists in the production of said Academy, the Boy Scouts of America, and the agency which sponsors Post # _________ and their respective advisors, members of employees, I have and do hereby assume all of the above mentioned risks and will hold them harmless from any and all liability, action and causes of action, debts, claims, demands of every kind and nature whatsoever, which may arise from my participation in or my going to and from any activities arranged for me by the aforementioned parties.

I have adequate insurance coverage through my family to cover my medical needs should I become ill or injured, and understand I must fully bear the cost of such treatment through such coverage.

The terms hereof shall serve as a release and assumption of risks for my heirs, executor and administrators and for all members of my family.

As a parent, legal guardian, or self, I understand the aforementioned and acknowledge so by signing this 3 page form. I swear the information contained on this form, which I have provided, is complete and accurate to the best of my knowledge.

PARENTS SIGNATURE _______________________________________________ DATED _________________

(If explorer is under 18)

ADVISOR SIGNATURE _______________________________________________ DATED _________________

EXPLORER SIGNATURE ______________________________________________ DATED ________________

3002 Wetmore Avenue