Form Center

2. PERSONAL INFORMATION
4. Last Name*
5. First Name*
6. Middle Name
8. Phone Number*

   (XXX) XXX-XXXX

9. Email Address*
11. Home Address*
12. City*

    Must live in the City of Ventura

13. State*
14. Zip Code*
16. School Name*
17. Grade Level
    -- Select One --9101112
19. Sex*
    -- Select One --MaleFemale
20. Height*
21. Weight*
22. Hair Color*
24. Eye Color*
25. Date of Birth*

    (XX/XX/XXXX)

26. Age*
27. Driver's License Number*

    (If not applicable, enter "N/A")

29. Vehicle Year/Make*

    (If not applicable, enter "N/A")

30. Model*

    (If not applicable, enter "N/A")

31. Color*

    (If not applicable, enter "N/A")

32. License Plate Number*

    (If not applicable, enter "N/A")

34. Insurance Information*

    (If not applicable, enter "N/A")

38. Father or Legal Guardian's Name*

    (Last, First)

39. Home Address*
41. Email Address*
42. Phone Number*

    (XXX) XXX-XXXX

46. Mother or Legal Guardian's Name*

    (Last, First)

47. Home Address*
49. Email Address*
50. Phone Number*

    (XXX) XXX-XXXX

54. EMERGENCY INFORMATION

    In case of an emergency, please provide an emergency contact other than the parent or guardian(s) listed above.

56. Name*

    (Last, First)

57. Relationship*
58. Phone Number*

    (XXX) XXX-XXXX

60. Home Address*
62. Physician's Name*

    (Last, First)

63. Address*
64. Phone Number*

    (XXX) XXX-XXXX

    
    

66. Do you have any medical concerns? (Allergies, Medications, Special Needs, etc.)*

    (If not applicable, enter "N/A")

70. REFERENCES

    Please list two adult references who can comment on your suitability for our program. References can be teachers, counselors, sports coaches, employers, etc. Do not list other relatives.

72. Reference 1: Name*

    (Last, First)

73. Phone Number*

    (XXX) XXX-XXXX

75. Address*
76. Title/Position*
78. Reference 2: Name*

    (Last, First)

79. Phone Number*

    (XXX) XXX-XXXX

81. Address*
82. Title/Position*
86. BACKGROUND INFORMATION

    Please answer all of the following questions. "Yes" answers alone may not cause your application to be rejected, however, any false statements or omissions of the truth will result in disqualification from the program.

88. Have you ever been arrested?*

    1. Yes
    2. No
89. Have you ever received a ticket?*

    1. Yes
    2. No
90. Have you ever had the police called on you, or had a negative police contact?*

    1. Yes
    2. No
92. Have you ever been under the influence of alcohol?*

    1. Yes
    2. No
93. Have you ever stolen anything?*

    1. Yes
    2. No
94. Have you ever used or possessed any illegal drugs, including marijuana?*

    1. Yes
    2. No
96. Have you ever been suspended from school?*

    1. Yes
    2. No
97. Have you ever been involved in a physical fight with someone else?*

    1. Yes
    2. No
98. Have you ever been a member of a gang, or associated with known gang members?*

    1. Yes
    2. No
100. Have you ever committed an act of vandalism?*

     1. Yes
     2. No
101. Have you ever been the victim of a crime?*

     1. Yes
     2. No
103. If you answered "yes" to any of the questions above, please explain in detail below. Include approximate dates, number of times you engaged in each activity, etc.
105. What is your current GPA?*
106. Please upload a copy of your last report card or transcript*
108. Please tell us why you want to be part of the Ventura Police Explorer Program*
112. AUTHORIZED RELEASE

     I understand that any portion of this application is subject to examination by the Ventura Police Department, and/or the staff of the Ventura Explorer POST #9258. I acknowledge that all of the information contained herein will be used solely for the Explorer POST, and for no other purpose. I hereby attest that all of the information contained herein is, to the best of my knowledge, true and correct.

114. Please check this box to acknowledge the Authorized Release stated above.*

     1. I acknowledge
115. By entering your name here, you are authorizing the above.*
116. Date/Time of Electronic Signature*
     Date/Time of Electronic Signature

     Date/Time of Electronic Signature
120. ACKNOWLEDGEMENT

     I hereby acknowledge that if I am selected as a member of the Ventura Police Explorer POST #9258, my primary objective will be to study the field of Law Enforcement and its possibilities for career opportunities. I acknowledge that teamwork is a necessary ingredient for the success of the POST. I will strive to achieve the objective and ideals of the POST and dedicate myself to the support of good law enforcement. I will maintain myself, both physically and mentally as an asset to the Ventura Police Department and the community.

122. Acknowledgment of the applicant.*

     1. I acknowledge
123. Name of Applicant*

     By entering your name here, you are acknowledging the above.

     
     

124. Date/Time of Electronic Signature*
     Date/Time of Electronic Signature

     Date/Time of Electronic Signature
126. Acknowledgment of the applicant's parent or guardian*

     1. I acknowledge
127. Name of Parent or Guardian*

     By entering your name here, you are acknowledging the above.

128. Date/Time of Electronic Signature*
     Date/Time of Electronic Signature

     Date/Time of Electronic Signature
Leave This Blank:


130. 1. Receive an email copy of this form.
131. Email address

     This field is not part of the form submission.

132. Submit

* indicates a required field