West Palm Beach Police Department
Explorer Post 148
Application for Membership
To Prospective Explorers and Parents:
In order to become a member of Explorer Post 148 the following criteria must be met:
Please fill out completely and return the following attached forms:
______ Explorer Post 148 Application
______ Personal Health & Medical Summary Form
______ Participation Authorization and Medical Release
In addition, please bring the following in person:
______ Pay $50.00 application fee. Cash or check to, West Palm Beach Police Explorer Post 148
______ 2 Letters of Recommendation from non-family member
______ Most recent Report Card, ( If you have not graduated high school )
Once all paperwork is turned in and the applicant has attended 8 consecutive Post meetings, the
Senior Advisor will interview the applicant and begin processing the application.
West Palm Beach Police Department Explorer responsibilities include, but are not limited to:
1. City wide events / details
2. Pay dues on time ($10.00 per month or fund raising efforts)
3. Attend Explorer meetings (Monday nights from 6:00 p.m. - 9:00 p.m.)
4. Look presentable to the public
5. Maintain a positive home/work/school environment
6. Have good moral character
The West Palm Beach Explorer Post 148 is sponsored by the West Palm Beach Police
Department. The Explorers are chartered through the Boy Scouts of America, Learning for Life
and are a member of the Florida Association of Police Explorers.
The purpose of the Post, is to incorporate police training into the lives of motivated young adults
who are ambitious about Law Enforcement as a career. At the West Palm Beach Police
Department, we incorporate our Explorers into the law enforcement community in a variety of
ways.
1. Hands on training and experience with top officers in specific fields
2. Exposure through our “Ride-Along” Program, after Explorer Academy attendance
3. Forge relationships with the City of West Palm Beach communities
4. Prepare for entry into the Police Academy or Criminal Justice career.
Uniforms are initially provided at no cost to the Explorer by the West Palm Beach Police
Department; however, replacement of lost or missing items / equipment must be absorbed by the
individual they were assigned to.
If you are interested in the West Palm Beach Police Explorers, please contact:
Officer Rick Moore
Senior Post Advisor
[email protected]
(561) 822-1755
West Palm Beach Police Explorer Application
Revised 08/13
Page 1
Post 148 Explorer Application
Date of Application: _____________
Start Date: _____________
(To be filled in by Senior Post Advisor)
Your Information:
Name: __________________________________________________________________
LAST
FIRST
MIDDLE
Address: ________________________________________________________________
STREET
CITY
STATE
ZIP
Home Phone # (____) _____-________
Cell #
(____) _____-________ Can you send and receive text messages? _____
Work Phone # (____) _____-________
E-mail Address __________________________________________________________
Age: _____
Date of Birth: _________
Sex: _____
Social Security #: ________________
Drivers License Number: _____________________________________________
Personal Information:
Height: ________ Weight: _______ Eye Color: _______ Hair Color: ________
Place of Birth: ___________________________________________________________
Do you have any friends or relatives in the Explorer program or the West Palm Beach
Police Department? If so, please name: ________________________________________
How long have you lived in Palm Beach County? _______________________________
Have you ever been a member of an Explorer Post before? _______
If yes, where? _______________________________________________________
Do you have any allergies, physical defects, or emotional conditions which would
interfere with your full participation in activities, examples: Running, swimming, self
defense training, firearms training, etc.: _______________________________________
Please Explain: __________________________________________________________
_______________________________________________________________________
Your Parent/Guardian’s information:
Occupation / Business: ____________________________________________________
Parent/Guardian Name: ______________________________ Relationship: __________
Parent/Guardian Work #: (____) _____-________
Other contact number: (____) _____-________
Your School / College Information:
What school do you attend? ________________________________________________
Grade: _____
Have you ever been suspended or expelled from any school? __________
If yes, give date, reason, and name of school: ___________________________________
________________________________________________________________________
________________________________________________________________________
West Palm Beach Police Explorer Application
Revised 08/13
Page 2
What school activities do you participate in (clubs, sports, band, etc):
________________________________________________________________________
________________________________________________________________________
May we contact school officials for a copy of your school records? __________________
Employer information:
Employer Name: _________________________________________________________
Employer Address: _______________________________________________________
Employer Phone Number: _________________________________________________
Manager Name: _________________________________________________________
Will you be able to attend most Explorer meetings, trainings, and activities? __________
Do you have an interest in Law Enforcement as a career? _________________________
Your Criminal History:
Have you ever been arrested? ___________ Date of Arrest: ________ Charge: ________
If Yes, Explain: __________________________________________________________
________________________________________________________________________
Arresting Agency: _____________________________
List all traffic tickets: ______________________________________________
Explain: _________________________________________________________
Have you ever been listed as a runaway juvenile? _______________________________
Failure to answer truthfully may disqualify this application.
References:
Please list three references of Teacher’s and/or adults not related to you.
Name
Phone #
Relationship
Address
Name
Phone #
Relationship
Address
Name
Phone #
Relationship
Address
If applicable, please list the name of the West Palm Beach School Board Police
Officer at your school
Officer’s Name
School
Phone #
INCLUDE A RECENT PHOTOGRAPH (wallet size)
West Palm Beach Police Explorer Application
Revised 08/13
Page 3
Authorizations:
Permission for participation and treatment (must be notarized)
I hereby attest that the health history and information provided herein are correct to the
best of my knowledge, and that my child, has permission to engage in all West Palm
Beach Police Department Explorer activities, training and travel, unless otherwise noted
by me in this section. I hereby authorize a representative of the West Palm Beach Police
Department, in case of emergency, to provide proper treatment including, but not limited
to, hospitalization, injections, anesthesia, surgery, and/or other medication deemed
necessary by said physician or hospital at the time. I also grant permission to release
medical information on my son/daughter incident to his/her participation in the above
activities. I will assume financial responsibility for this medical treatment either directly
or through insurance.
___________________________________
Signature of Parent or Guardian
__________________
Date
___________________________________
Parents Phone Number
STATE OF Florida
COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before
me this __________ by _____________________
Date
Name of person acknowledging
who personally known to me or who has produced
__________________ as identification and who
Type of identification
did(did not) have the oath.
________________________
Notary Public
Commission Number: _________
________________________
Name of Notary typed, printed or stamped
West Palm Beach Police Explorer Application
Revised 08/13
Page 4
Parental Permission for Media Release
(Must Be Notarized)
The undersigned parent/guardian does fully realize that his/her child,
__________________, may appear in the newspaper, on film, video tape or in live
production while participating in West Palm Beach Police Department Explorer
functions. The undersigned does further realize that the above named child will receive
no compensation for appearing in newspaper, on film, video tape, or live production and
understands that the West Palm Beach Police Department is in no way responsible for
any liability arising from such appearance. The undersigned parent/guardian and Explorer
applicant have no objection to appearing in the newspaper, on film, video tape or in live
production, and gives the West Palm Beach Police Department full permission to use
photos and videos without prior notice.
________________________________
__________________
Parent/Guardian Signature
Date
________________________________
__________________
Explorer Signature
Date
Affidavit
STATE OF Florida
COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before
me this __________ by _____________________
Date
Name of person acknowledging
who personally known to me or who has produced
__________________ as identification and who
Type of identification
did(did not) have the oath.
________________________
Notary Public
Commission Number: _________
________________________
Name of Notary typed, printed or stamped
West Palm Beach Police Explorer Application
Revised 08/13
Page 5