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Northeast Regional Law Enforcement Educational Association (NERLEEA)
CADET POLICE ACADEMY
ADULT LEADER APPLICATION
UNIVERSITY OF HARTFORD - WEST HARTFORD, CT
July 26 to August 1, 2015
Name: ______________________________________________ D.O.B. _______________
Send Mail to: [ ] HOME ADDRESS [ ] DEPARTMENT ADDRESS
Address: ___________________________________ City: _____________________ State: ________ Zip:_____________
Phone: __________________________ Sex: ______
__________
Cell number to be used to contact you while at the academy: _______________________
E-Mail Address: _______________________________________ Police Department: ______________________________
Chief of Police: _________________________________ Dept. Address: ________________________________________
City: __________________________ State: _________ Zip: __________ Dept. Telephone: __________________________
Sworn Officer? ____________
________ RANK ________________
DUTIES:______________________________________________ If NOT a police officer, list your occupation/duties:
___________________________________________________________
Have you ever attended any other youth
________
academy? ____________ If YES, How Many years? _____, Where _____________ If YES, List previous assignments: ______________________, _________________________, _______________________ Do you hold any special certifications
or training:_____________________________________________________________
________
________
Have you ever been arrested? ____________: If YES, did it result in conviction? ____________:
If yes, please explain; ______________________________________________________________________________
WHAT AREA WOULD YOU LIKE TO BE ASSIGNED TO AT THE ACADEMY? (MANDATORY FOR ALL ADULT LEADERS TO PARTICIPATE IN PROGRAM – MUST CHOOSE 2) [ ] Firing Range Instructor (Help NEEDED) [ ] Dorm Monitor / Hall Monitor [ ] Drill Instructor (All Programs) ________ [ ] Event Monitor [ ] Role Player (Mock PD) [ ] Office Staff [ ] Prac cal Skills Program [ ] OTHER __________________
[ ] Ac vi es (Assist where needed) [ ] OTHER __________________ THIS FORM IS FOR INFORMATION COLLECTION PURPOSES ONLY!
In order to register for the Academy, a signed agreement and printed online registration must be submitted with
ALL forms EXCEPT for medical forms which must be brought with the attendee on the morning of the academy.
NERLEEA – CPA
P.O. Box 199
Niantic, CT 06357
ADULT registration is limited to 100 participants.
A $450.00 fee will be charged to all Adults in order for them to attend the academy and stay overnight.
Registrations must be received (postmarked by deadline) and PAID IN FULL by June 30, 2015 or have a
Government PO in place by that date in order to be eligible for the $450.00 fee.
If paid between July 1, 2015 and July 8, 2015, the fees will be $525.00 per person. NO Registrations will
be accepted after July 8, 2015, except at the discretion of the ACADEMY DIRECTOR and those
approved application fees will be $650.00, no exception.
You may substitute one adult for another without incurring the additional fees.
All fees are non-refundable after the June 30, 2015 deadline regardless of the situation due to
associated costs incurred. Dates will be determined by postmark cancellation.
Checks should be made payable to:
YOUR PERSONAL CADET/EXPLORER POST
The Post Advisor will send in one (1) Check to cover ALL participants.
I understand I need to make payment arrangements directly with my post in relationship with this
application. I also understand that my reservation will be forfeited if I fail to attend the academy.
I understand that all fees are non-refundable AFTER the June 30, 2015 deadline. I understand that
Linens and transportation costs to and from University of Hartford are not included in the registration fee.
I understand that I am paying for the cost to attend the program regardless of whether I stay on campus
or whether I eat at the cafeteria as all fees paid are paid to NERLEEA for attending the program.
I Understand and agree that as an attending advisor, I must assist and work with one of the
programs during the academy and that my failure to assist may result in a call to my Chief of
Police and/or the dismissal of my post from the academy WITHOUT any refunds.
I agree that I either have a copy of a current/valid youth protection certificate on file
with NERLEEA and/or have included an update copy with this application.
ALL ADULT LEADERS MUST BE AT LEAST 21 YEARS OF AGE AND AFFILIATED WITH A
PROGRAM THAT IS REGISTERED WITH NERLEEA AS A MEMBER. ALL ADULT
LEADERS AGREE TO BE RESPONSIBLE FOR THEIR CADETS AND WILL STAY ON
CAMPUS AT NIGHT DURING THE ACADEMY, UNLESS PRIOR ARRANGEMENTS HAVE
BEEN MADE WITH THE EXECUTIVE COMMITTEE. BY SIGNING BELOW, I AGREE
THAT ALL STATEMENTS MADE ABOVE ARE TRUE AND CORRECT.
___________________________________
PRINT Name
___________________________________
Signature
___________________________________
Date
___________________________________
Contact # at Academy
ADVISOR:
Please attach this to the online Cadet Registration after printing, then MAIL with POST payment
to:
NERLEEA
P.O. Box 199
Niantic, CT 06357
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Camper
Staff
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Adults OVER the age of 40 are required to obtain a new Exam EVERY Year.
Please Return Completed Form to the Camp - DO NOT MAIL!
Name
__________ Date of Birth
Guardian
Address
Phone
Telephone
Emergency Contact
Date of Arrival at Camp: ____________________________________________ Departure Date:_____________________________________________
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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________ May participate in all camp activities
________ May participate except for: ______________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Medical information pertinent to routine care and emergencies:___________________________________________________________________________
_____________________________________________________________________________________________________________________________
Is this individual taking prescription or over the counter medication(s)?
YES
NO
If yes, indicate names of
medication(s):____________________________________________________________________________________________________
Does the individual have allergies?
YES
NO
Explain ________________________________________________
Is the individual on a special diet?
YES
NO
Explain ________________________________________________
Does the individual have special needs?
YES
NO
Explain: ________________________________________________
This camper/staff is up-to-date on all the following routine childhood immunizations currently recommended by the American
Academy of Pediatrics and National Advisory Committee on Immunization Practices:
<HV1R
Measles
<HV1R
Hepatitis B
Mumps
Diphtheria
Rubella
Pertussis
Chickenpox
Pneumococcal
conjugate
Polio
Tetanus
Comments: __________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Print name of medical care provider: _______________________________________________
Medical care provider’s address: __________________________________________________
Medical care provider’s: City/Town______________________________ST___________Zip Code__________
Signature of Physician, PA, APRN or RN
Date Form Signed
______________________________________________________________
Telephone Number
CT Cadet Police Academy
Firearms Certification Form
FIREARMS
Mail this form with Registration
UNIT NAME _________________________________________________
Notice – This form must accompany all firearms forms in order for any
of the Post's Members to participate in the Firearms Range Training.
ADVISORS CERTIFICATION: (Choose one a return form with paperwork)
I CERTIFY THAT THE CADETS FROM THE ABOVE LISTED POST HAVE
SUCCESFULLY COMPLETED THE PERSCRIBED FIREARMS SAFETY COURSE
AS SET DOWN BY OUR OWN POLICE DEPARTMENT.
THE CADETS FROM THE ABOVE LISTED POST HAVE NOT ATTENDED ANY
FIREARMS SAFETY COURSES AND ARE NOT AUTHORIZED TO ATTEND THE RANGE.
ADVISOR'S NAME ____________________________________
(PLEASE PRINT)
ADVISOR'S SIGNATURE_______________________________
ADVISOR'S CONTACT #: ______________________________