EXPLORER APPLICATION

Personal Information:

Name: *

First

Middle

Last

Date of Birth: *

Social Security Number: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Cell Phone:

Email Address: *

Email

Confirm Email

Driver's License # and State:

(example: A1234567 - CA)

Click here if you do not have a Driver's License:

N/A

Age: *

Sex: *

Height: *

Weight: *

Hair Color: *

Eye Color: *

Current School:

School Phone Number:

Grade:

Counselor or Teacher:

Employer:

Employer Phone Number:

PARENTAL INFORMATION

Mother's Information:

Name

First

Middle

Last

Date of Birth:

Social Security Number:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Cell Phone:

Email Address:

Email

Confirm Email

Father's Information:

Name:

First

Middle

Last

Date of Birth:

Social Security Number:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Cell Phone:

Email Address:

Email

Confirm Email

Legal Guardian's Information:

Name

First

Middle

Last

Date of Birth:

Social Security Number:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone:

Cell Phone:

Email Address:

Email

Confirm Email

EMERGENCY CONTACT INFORMATION:

Emergency Contact #1

(Relative or close friend/neighbor not listed above)

Name: *

First

Last

Relationship: *

Home Phone: *

Work Phone: *

Cell Phone: *

Email Address: *

Email

Confirm Email

Emergency Contact #2

(Relative or close friend/neighbor not listed above)

Name:

First

Last

Relationship:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Email

Confirm Email

MEDICAL INFORMATION

Physician's Name: *

Office Phone Number: *

Health insurance carrier: *

Health insurance policy/group number: *

List any physical limitations:

List any medications you currently take, also reason, and frequency for using them:

List any allergies: (Food, Medications, Insects, Plants):

List any other information or concerns the Explorer staff needs to know:

PERSONAL HISTORY:

Have you ever been arrested? *

Yes
No

Have you ever received a citation? *

Yes
No

Have you ever used or experimented with alcohol or any drugs including marijuana? *

Yes
No

If you answered yes to any of the above, explain in detail:

PERSONAL REFERENCES

References (Must be completed- Include names of teachers, coaches, neighbors and friends)

Personal Reference #1

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone: *

Work Phone: *

Cell Phone: *

Email Address: *

Email

Confirm Email

Personal Reference #2

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone: *

Work Phone: *

Cell Phone: *

Email Address: *

Personal Reference #3

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone: *

Work Phone: *

Cell Phone: *

Email Address: *

Email

Confirm Email

Personal Reference #4

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone: *

Work Phone: *

Cell Phone: *

Email Address: *

Email

Confirm Email

AUTOBIOGRAPHY:

(Tell us about you and the reasons you want to be an Explorer) *

Personal Information:

PARENTAL INFORMATION

Mother's Information:

Father's Information:

Legal Guardian's Information:

EMERGENCY CONTACT INFORMATION:

Emergency Contact #1

Emergency Contact #2

MEDICAL INFORMATION

PERSONAL HISTORY:

PERSONAL REFERENCES

Personal Reference #1

Personal Reference #2

Personal Reference #3

Personal Reference #4

AUTOBIOGRAPHY:

MENIFEE POLICE DEPARTMENT

LOBBY HOURS

PHONE NUMBERS