Reserve/Intermittent Recruit Officer Course Application
This course is 315/335* Hours
INSTRUCTIONS: Mail a complete, signed Application and tuition requirement to the liaison located at the training venue you are applying to.
Visit this Reserve/Intermittent Recruit Officer Course link to locate a Reserve/Intermittent Police Academy in your area..
Police Academy Academy Start Date
Sponsoring Dept.
Department contact
Dept. Contact E-mail
Reserve/Intermittent Officer
Employment status upon graduation:
Revised October 2015
Date
Sponsored [ No employment]
Dept. Contact Telephone
Commonwealth of Massachusetts
Municipal Police Training Committee
“Training for Today, Planning for the Future”
Please type all information requested.
[*An additional 20 hours of MPTC-certified firearms training is required if the officer will be armed with a firearm.]
Student's First name
Student's Last name
Last Four SSN
Student's D.O.B.
Student's Personal E-mail
Alt. Phone:
Telephone Phone:
Zip CodeState
CityStudent's Address
Student's FULL Middle Name
Driver's License
Gender
Country
Minimum Age is 18
Chronic medical/physical conditions: (List all past or present, please describe.)
Are you currently taking medications, prescribed or OTC? (List long or short term.)
None
All students must complete the following.
Disclosure of the following does not affect Applicant's ability to enroll. Attach additional pages if necessary.
None
Have you experienced dizziness, faintness, chest pain or shortness of breath during exertion? If yes, explain.
None
Known Allergies: (List all foods, medicines, plants, animal fur, insects, etc.)
None
ID# Medical Insurance Company
Telephone
RelationshipEmergency Contact
MM/DD/YYYY
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Page 2 of 3
Revised October 2015
MUNICIPAL POLICE TRAINING COMMITTEE RECRUIT OFFICER COURSE
WAIVER, RELEASE, AND INDEMNIFICATION AGREEMENT
FOR STUDENT OFFICERS
I, , in consideration of being permitted to participate in the Municipal Police
Training Committee (“MPTC”) Basic Training Program, hereby acknowledge and agree as follows:
1. I understand the nature of the activities I may perform while involved in the MPTC Basic Training Program
(hereafter referred to as “police training”) requires mental judgment and a high degree of physical fitness, agility, and dexterity,
and that this may include strenuous exercise in varying environmental conditions, which requires physical fitness, strength, and
stamina.
2. I understand that police training involves the risk of injury or death, and I voluntarily assume these risks.
3. I understand that the Commonwealth of Massachusetts, the MPTC, and the MPTC Academy will NOT provide medical
or health insurance coverage to me during any aspect of my participation in the police training described herein. I hereby
represent and warrant that I am and will be covered throughout the police training activity by a policy of accident and health
insurance that provides coverage for injuries I may sustain in the course of my participation in the training program. I understand I
will be required to show proof of insurance coverage prior to my participation in the police training program.
4. I understand that I am responsible for attending all safety training required by the class in which I am enrolled. I understand that
I must abide by all the rules and policies set forth by the MPTC Academy. I understand that the rules and guidelines of the MPTC
Basic Recruit Training Program are intended to protect me and other participants from harm, to protect property from damage,
and to make my learning experience and the learning experience of other participants enjoyable. I understand that my failure to
abide by the rules and policies may result in my being denied admission to or may result in my being dismissed from the training
program.
5. I certify the information provided on my registration form submitted in connection with the police training program is true and
accurate.
6. I, individually, and on behalf of my heirs, successors, assigns and personal representatives, hereby agree to indemnify, defend
and hold harmless the Commonwealth of Massachusetts, the Municipal Police Training Committee, the MPTC Academy, and their
employees, agents, and representatives, from any and all liability whatsoever for any and all damages, losses, or injuries (including
death) I sustain to my person or property or both, including but not limited to any claims, demands, actions, causes of action,
judgments, expenses and costs, including attorneys' fees, which arise out of, result from, occur during, or are connected in any
manner with my intentional and/or negligent conduct during my participation in the police training program.
7. To the extent authorized by law, I, individually, and on behalf of my heirs, successors, assigns and personal representatives,
hereby release and forever discharge the Commonwealth of Massachusetts, the Municipal Police Training Committee, the MPTC
Academy, and their employees, agents, and representatives, from any and all liability, loss, damage or expense, including attorneys
fees, that they or any of them incur or sustain as a result of any claims, demands, actions, causes of action, damages, judgments,
costs or expenses, including attorneys' fees, which arise out of, occur during, or are in any way connected with my intentional and/
or negligent conduct during my participation in the police training program.
8. I agree that this Waiver, Release and Indemnification Agreement is to be construed under the laws of the Commonwealth of
Massachusetts and that if any portion hereof is held invalid, the balance hereof shall, notwithstanding, continue in full legal force
and effect.
CERTIFICATION BY APPLICANT: I, the above-mentioned Applicant agree to comply with all rules and regulations set forth by the Municipal
Police Training Committee with regard to its training programs and understand that I may be subject to sanctions for infractions thereof,
including possible notification of the department head and dismissal from training. Further, I certify that I am in good health, physically fit
and agree that in the case of accident or illness, the MPTC training staff may take whatever actions are necessary to arrange for emergency
medical services. I understand I am responsible for maintaining health care coverage throughout my participation in the training
program. In the case of illness or injury resulting from training, all necessary medical expenses will lie solely on me, the Applicant, unless
other arrangements have been made with my sponsoring agency. I affirm I have checked with my sponsoring agency to clarify medical
coverage issues. Further, I agree that all issues of civil liability shall be determined in accordance with Massachusetts General Laws.
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS ENTIRE DOCUMENT, THAT I UNDERSTAND ITS TERMS, THAT BY SIGNING IT I AM GIVING
UP SUBSTANTIAL LEGAL RIGHTS I MIGHT OTHERWISE HAVE, AND THAT I HAVE SIGNED IT KNOWINGLY AND VOLUNTARILY.
Applicant's Signature Date
Page 3 of 3
CERTIFICATION BY THE SPONSORING AUTHORITY: I, ,
agree to provide the support listed below
to , a Student Officer to be hired or sponsored by the department:
Revised October 2015
1. Insure that for the first day of the Academy the Student Officer has their tuition in the form of either a department, cashier's or
bank teller's check or money order.
2. Insure that the Student Officer has provided proof of adequate medical insurance coverage, including emergency room
coverage, which will remain in effect through the entire academy program.
3. Insure that an adequate background and CORI check has been conducted prior to the Student Officer beginning the academy.
4. Insure that the Student Officer has all required uniforms and equipment outlined in the Student Officer Manual for the first day
of the Academy.
I, the Sponsoring Authority, approve the above-mentioned Applicant to attend Recruit Officer Training and agree as the Sponsoring
Authority of the sponsoring agency to abide by the training regulations as established by the Municipal Police Training Committee and
to require the Applicant to do the same. I understand that the program may include physical skills training, which present inherent
risks. I agree that in the case of illness or injury, the training staff may take whatever actions are needed and acknowledge that the
costs of medical services related to illnesses and injuries resulting from training are to be borne by the student, unless other
arrangements have been made with my agency. I agree that all issues of civil liability shall be determined in accordance with
Massachusetts General Laws.
Sponsoring Authority's Signature Rank Date
Department Chief
Telephone
StateCityDepartment address
Dept. Fax Number
Zip Code
MUNICIPAL POLICE TRAINING COMMITTEE
RESERVE/INTERMITTENT RECRUIT OFFICER COURSE
CERTIFICATION BY SPONSORING AUTHORITY
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