Fill - Free fillable Application Packet Cover Sheet (New Jersey State Police) PDF form

Last Name, First Name, MI

Application Packet Cover Sheet

Name:

_____________________________

Required Documents Checklist

S.P.894

TYWApplication

S.P.894A Medical/Insurance/EmergencyInformation

PhotocopyofMedicalInsuranceCard(front/back)

S.P.894B PhysicianMedicalApprovalForm

S.P.479 ConsentforPhotograph&Audio/VisualRelease

LeadershipEssay(500wordminimum)

Return this form and all required documents no later than May 15

, 2020 to:

Division of State Police

School Safety & Outreach Unit

Attn: Trooper Youth Coordinator

P.O. Box 7068, Bldg. #4, West Trenton, NJ 08628-0068

Or scan (PDF format ONLY) and email to:

lpptrooperyouth@gw.njsp.org

Official

Use

Only

CLEAR FORM

NEW JERSEY STATE POLICE

Trooper Youth Week — Application

1. Applicant Information - to be completed by Student

Name (Last, First, MI) Gender Age Date of Birth Email Address

Address (Number & Street, City, State, ZIP Code) County Telephone

T-Shirt

Size

XXL

Other

Race or Ethnic Group (Completion of this question

is voluntary. The requested information will be kept

confidential and used for statistical purposes.)

Native Hawaiian/Other Pacific Islander (Not Hispanic/Latino)

Native Amer./Alaskan Native (Not Hispanic/Latino)

Asian (Not Hispanic/Latino)

African American/Black (Not Hispanic/Latino)

White (Not Hispanic/Latino)

2 or more races (Not Hispanic/Latino)Hispanic or Latino

Parent/Guardian Name Parent/Guardian Home Telephone Parent/Guardian Work Telephone Parent/Guardian Cell Phone (24 Hr. Emergency)

Parent/Guardian Address if different from above (Number & Street, City, State, ZIP Code) Parent/Guardian County Parent/Guardian Email Address

2. Essay - to be completed by Student

The applicant shall submit an essay describing leadership traits they consider important and how these attributes relate to the law enforcement profession. The

essay may meet or exceed 500 words but shall not be less than the 500 word minimum. Failure to submit the required essay may result in non-selection.

3. School Certification - to be completed by High School Guidance Counselor

Name of High School Address (Number & Street, City, State, ZIP Code) Telephone

I hereby certify the Applicant is in good academic standing and the Applicant will in all likelihood successfully complete their junior year in high school. Additionally,

sophomores who are currently 17 years of age may also be eligible. The Applicant must not have reached their 18th birthday prior to the graduation date of their Trooper

Youth Week class.

Name of Guidance Counselor

Guidance Counselor Signature Date

Applicant is Recommended by Relationship to Applicant Telephone

4. Reference

Other:

Religious Leader

Community Representative

High School Principal

Guidance Counselor

NJSP/Law Enforcement

I hereby certify that the Applicant named above is honest, of good reputation, and sound moral character.

Reference Signature Date

5. Available Weeks - to be completed by the Parent/Guardian

Return this form no later than May 15, 2020 to: Division of State Police, School Safety & Outreach Unit

Attn: Trooper Youth Coordinator

P.O. Box 7068, Bldg. #4, West Trenton, NJ 08628-0068

or scan (PDF format ONLY) and email to: lpptrooperyouth@gw.njsp.org

S.P. 894 (Rev. 03/20)

6. Waiver & Release - to be completed by the Applicant AND the Parent/Guardian

In consideration of the New Jersey State Police (NJSP) allowing me to participate in the Trooper Youth Week program at the NJSP Academy, I, the undersigned, for myself,

my heirs, executors, administrators and assigns, hereby waive and release any and all claims for damages or loss to my person and/or property that may be caused by

any act, or failure to act, of the NJSP, its officers, agents, employees or recruits. I assume the risk of any and all dangerous conditions in and about the training area and

Academy property and waive any and all specific notice of the existence of such conditions.

My participation in the Trooper Youth Week program is purely voluntary and done at my own risk. I expressly acknowledge that there is some risk in participating in law

enforcement training exercises. Knowing that some risk exists, I nevertheless voluntarily assume all risks of loss, damage or injury that may be sustained while

participating in these exercises, even though they may arise out of the negligence of the persons entities listed above. I agree to accept and abide by the Trooper Youth

Week Rules & Regulations as established by the NJSP and to obey the directions of the designated training officers. Failure to do so SHALL result in my removal from the

Trooper Youth Week program.

I have read and understand the contents of this WAIVER & RELEASE as well as the TROOPER YOUTH WEEK RULES & REGULATIONS and I am signing voluntarily.

THE SIGNATURE OF A PARENT OR LEGAL GUARDIAN IS REQUIRED.

DateCandidate Signature DateParent/Guardian Signature

In the event you are selected, please be aware that no applicant is guaranteed their week of choice. Place a number 1 or 2 on

the lines to the left for your preferred week of attendance. You will be notified as to your acceptance in the program as

decisions are finalized.

_____ July 27-30, 2020

_____ August 11-14, 2020

_____ No Preference

S.P. 894A (Rev. 01/20)

NEW JERSEY STATE POLICE

Trooper Youth Week — Medical/Insurance/Emergency Information

The Trooper Youth Applicant named above is not covered by health insurance. As a condition of participation, I hereby acknowledge that as

the parent or legal guardian, that I shall bear and be liable for any and all medical, hospital, or related costs, damages, losses, and expenses

incurred due to any injuries or illness that he or she may suffer during their participation in the Trooper Youth Week Program. I further

acknowledge and agree that both the New Jersey State Police and the State of New Jersey will have no financial responsibility for any of the

costs or expenses outlined above.

To be completed by Parent/Guardian. Mark N/A when information is not applicable. Attach additional information as necessary.

Trooper Youth Applicant:

Last Name, First Name, MI Date of Birth

A. Explain any existing medical conditions/allergies/nutritional requirements the Trooper Youth Applicant may have:

B. List any medications (over-the-counter and prescription,

ex.: Tylenol, Motrin, Benadryl, etc.) to be taken during the week:

Medication Dosage Condition prescribed for

Side Effects Prescribing Physician Physician Telephone

Medication Dosage Condition prescribed for

Side Effects Prescribing Physician Physician Telephone

Medication Condition prescribed forDosage

Side Effects Prescribing Physician Physician Telephone

The Trooper Youth will bring four full days' supply of medication only.

Prior to Trooper Youth's arrival, all medications are to be labeled and stored in their original container or prescription

container, as applicable and in accordance with manufacturer instructions.

FAILURE TO COMPLY WILL PREVENT THE STUDENT FROM PARTICIPATING IN THE TROOPER YOUTH WEEK PROGRAM.

C. Emergency Contact Information:

Name Relationship 24 Hour Telephone

I, the Parent/Guardian, grant the New Jersey State Police permission to seek/provide medical attention in case of

emergency should I not be able to be contacted.

Parent/Guardian Name Physician Name Physician TelephoneParent/Guardian Signature

D. Health Insurance Information:

NOTE: A PHOTOCOPY OF YOUR MEDICAL INSURANCE CARD (Front & Back) MUST BE ATTACHED TO THIS FORM.

Insurance Company Name Address Telephone

Policy Number Group Number Policy Holder Name

Policy Holder Address Telephone Policy Holder Date of Birth Relationship to Trooper Youth

Trooper Youth Applicant has no health insurance. If insurance coverage is NOT available for the participant, please complete the section below:

Parent/Guardian Name

Signature of Parent/Guardian Date

Dear Physician:

The following individual has submitted an application to participate in the New Jersey State Police (NJSP) Trooper Youth

Week Program.

Name: ___________________________________________________________________________________________

Address:__________________________________________________________________________________________

As part of the Trooper Youth Week Program, the NJSP requires each applicant to undergo a medical examination by a

licensed physician. Trooper Youth Applicants should be in good physical health and able to participate in physical ﬁ tness ac-

tivities (marching, running on all surfaces [blacktop, grass, sand]), calisthenics and organized athletic sports. Trooper Youth

Week is a residential program. Applicants receive room and board at the NJSP Academy in Sea Girt, NJ.

Physician’s Statement (Please check one box)

 I have examined the above named applicant and ﬁ nd he/she can safely perform in the program.

 I have examined the above named applicant and ﬁ nd he/she cannot safely perform in the program.

Examination shall be consistent with the 2014 14-Element AHA/ACC Recommendations.



Examination date MAY NOT be greater than one year old from the last day the applicant attends the Trooper

Youth Week Program.

Physician’s Signature

Date

The 14-Element, American Heart Association/American College of Cardiology Recommendations for Preparticipation

Cardiovascular Screening of Competitive Athletes:

(Personal history)

1. Exertional chest pain/discomfort

2. Unexplained syncope/near-syncope†

3. Excessive exertional and unexplained dyspnea/fatigue, associated with exercise

4. Prior recognition of a heart murmur

5. Elevated systemic blood pressure

(Family history)

6. Premature death (sudden and unexpected, or otherwise) before age 50 years due to heart disease, in one or more relatives

7. Disability from heart disease in a close relative under 50 years of age

8. Speciﬁ c knowledge of certain cardiac conditions in family members: hypertrophic or dilated cardiomyopathy, long-QT syndrome or

other ion channelopathies, Marfan syndrome, or clinically important arrhythmias

(Physical examination)

9. Heart murmur‡

10. Femoral pulses to exclude aortic coarctation

11. Physical stigmata of Marfan syndrome

12. Brachial artery blood pressure (sitting position) §

13. If individual has been restricted from participation in sports in the past

14. If individual has had prior testing for the heart, ordered by a health care provider

*Parental veriﬁ cation is recommended for high school and middle school athletes.

†Judged not to be neurocardiogenic (vasovagal); of particular concern when related to exertion.

‡Auscultation should be performed in both supine and standing positions (or with Valsalva maneuver), speciﬁ cally to identify murmurs of dynamic left ventricular outﬂ ow tract obstruction.

§Preferably taken in both arms.

Please Type or Print:

Physician’s Name: _______________________________________________________________________________

Address: _______________________________________________________________________________________

Afﬁ x Physician’s Ofﬁ ce Stamp:

(Must be M.D. or D.O.; Physician Assistant or

Nurse Practitioner is NOT acceptable.)

NEW JERSEY STATE POLICE

Trooper Youth Week - Physician Medical Approval Form

Please list any relevant restrictions or limitations if any:

S.P. 894B (Rev. 11/18)

NEW JERSEY STATE POLICE

Consent for Photograph & Audio/Visual Release Form

The New Jersey State Police (NJSP) requests your permission to reproduce through printed, audio, visual, or

electronic means, activities in which you (the participant) or your child has engaged in for the following respective

NJSP Programs:

☐Trooper Youth Week, ☐Internship Program, ☐NJSP Explorer Post, ☐Other_______________________

Your authorization will enable us to use the photographs and/or video footage taken during the respective program

to promote the program through the use of mass media, displays, brochures, websites, etc.

• I, as a parent or guardian of the below-named youth, or as an adult participant, fully authorize and grant

the NJSP and its authorized representatives the right to print, photograph, record, and edit as desired, the

name, image, likeness, and/or voice of myself or the below-named youth on audio, video, film, slide, or

any other electronic and printed format currently developed for the purpose stated or related to the above.

• I understand and agree that the use of such photographs and video will be without any compensation to

me personally, the youth, or the youth’s parent/guardian.

• I understand all photos and/or videos will be property of the NJSP. Photos and/or videos may be used

without specific notification.

• I understand and agree that the NJSP and/or its authorized representatives shall have the exclusive right,

title, and interest, including copyrights, of such photographs and video recordings.

• I understand and agree that the NJSP and/or its authorized representatives shall have the unlimited right

to use the photographs or videos for any purpose stated or related to the above.

• I hereby release and hold harmless the NJSP and its authorized representatives from all actions, claims,

damages, costs, or expenses, including attorney's fees, brought by myself, the youth, and/or the

parent/guardian which relate to, or rise out of, any use of these photographs and/or videos as specified

above.

I have read and understand the contents of this Consent for Photograph & Audio/Visual Release Form and I am

signing voluntarily.

_________________________________ ________________________________ __________________

Participant – Print Name Participant Signature Date

_________________________________ ________________________________ __________________

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Fillable Application Packet Cover Sheet (New Jersey State Police)

Fill Online, Printable, Fillable, Blank Application Packet Cover Sheet (New Jersey State Police) Form

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