Certified Armed Protection Specialist and High Threat Protection Specialist

Certified Armed Protection Specialist and High Threat Protection Specialist

ApplicationForm II

[ ] Certified Armed Protection SpecialistAnticipated Date of Attendance: ______

[ ] High Threat Protection SpecialistAnticipated Date of Attendance: ______

Name:______

Email:______Phone: ______

DEPOSIT

In order to complete your application, you must submit a $50 deposit (cash or credit card only). This fee will be processed with your application. Once you attend the first day of class, we will refund you the full amount of the deposit.

[ ] Cash[ ] Credit Card – Card #: ______Exp.: ______

Name on Card: ______

EMERGENCY CONTACT INFORMATION

Name (print):______Relationship:______

Address:______

Email:______Phone:______

MEDICAL EMERGENCY INFORMATION

List any medications or supplements you are taking or any medical treatments you are undergoing. Include the name of the substance or treatment and its purpose. Include both prescription and over-the-counter drugs and supplements (if you need to attach additional sheets, please do so):

______

______

______

Do you have medical/health insurance?[ ] YES [ ] NO Military health benefits? [ ] YES [ ] NO

List Health Insurance Carrier: ______

Policy/Tricare #: ______Contact #: ______

If active duty, your Tricare ID is your social. If a Veteran, please indicate your benefits number.

In a medical emergency arising during the course of the program, I grant the District acting through its designated supervisory personnel full authority to take any action deemed necessary to protect my health and safety at my expense, including, but not limited to, placing me under the care of a doctor, hospital and/or other qualified medical personnel to examine and/or treat.

______

Applicant’s SignatureDate

HEALTH INFORMATION

This information will be kept confidential. It is for qualification purposes only and will only be shared with those directly involved in the program.

In order to enroll in this program, students will be required to do a number of high stress, physically demanding activities. It is important that you are physically fit and able to perform all activities within the program. To help us determine your eligibility, please answer the following questions:

Gender: ______Height: ______Weight: ______

Please list any dietary restrictions: ______

______

How frequently do you consume alcohol?

[ ] Never[ ] Less than once a month[ ] 1-2x a month[ ] 1-2x a week [ ] Daily

Do you [ ] smoke cigarettes or [ ] dip? How frequently?

[ ] Never[ ] Less than once a month[ ] 1-2x a month[ ] 1-2x a week [ ] Daily

How frequently do you feel depressed?

[ ] Never[ ] Less than once a month[ ] 1-2x a month[ ] 1-2x a week [ ] Daily

How frequently do you feel anxious?

[ ] Never[ ] Less than once a month[ ] 1-2x a month[ ] 1-2x a week [ ] Daily

How often do you take supplements or vitamins to help you gain or lose weight or improve your performance?

[ ] Never[ ] Less than once a month[ ] 1-2x a month[ ] 1-2x a week [ ] Daily

How frequently do you exercise?

[ ] Never[ ] Less than once a month[ ] 1-2x a month[ ] 1-2x a week [ ] Daily

For approximately how long do you exercise each time?

[ ] Less than 20 minutes[ ] 20-40 minutes[ ] 40-60 minutes[ ] over an hour

When was your last physical exam?

[ ] Within the last half year[ ] Within the last year[ ] 1-2 years ago[ ] over 2 years ago

Have you ever had, or do you currently have…

1. Restriction from sports/PT for a health related problem?

1. An injury or illness since your last physical exam?

1. A chronic or ongoing illness (such as diabetes or asthma)?

1. Surgery, hospitalization, or any emergency room visits?

1. Any allergies to medications?

1. Any allergies to bee stings, pollen, latex or foods? If yes, please explain below (also indicate medication you take for allergic reaction)

1. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or clotting disorders?

1. A blood relative who died before age 50?

If you answered YES to any of the above questions, please explain further (include relevant dates):

______

______

______

______

Have you ever had, or do you currently have any of the following head-related conditions…

1. Concussion or head injury?

1. Memory loss?

1. A seizure?

1. Frequent or severe headaches (with or without exercise)?

1. Fuzzy or blurry vision?

1. Sensitivity to light/noise?

1. Numbness or tingling in your arms, hands, legs or feet?

If you answered YES to any of the above questions, please explain further (include relevant dates):

______

______

______

Have you ever had, or do you currently have, any of the following heart-related conditions…

1. Restriction from sports/PT for heart problems?

1. Chest pain or discomfort?

1. Heart murmur?

1. High blood pressure?

1. Elevated cholesterol level?

1. Heart infection?

1. Dizziness or passing out during or after exercise without known cause?

1. Has a provider ever ordered a heart test (EKG, echocardiogram, stress test, etc.)?

1. Racing or skipped heartbeats?

1. Unexplained difficulty breathing or fatigue during exercise?

If you answered YES to any of the above questions, please explain further (include relevant dates):

______

______

______

Have you ever had, or do you currently have, any of the following eye, ear, nose, mouth or throat conditions…

1. Vision problems? Please note below whether you wear contacts, eyeglasses, or protective wear.

1. Hearing loss or problems? Please note below whether you wear hearing aides or implants.

1. Nasal fractures or frequent nose bleeds?

1. Wear braces, retainer or protective mouth gear?

1. Frequent strep or any other conditions of the throat?

If you answered YES to any of the above questions, please explain further (include relevant dates):

______

______

______

Have you ever had, or do you currently have, any of the following neuromuscular/orthopedic conditions…

1. Numbness, a “burner”, “stinger” or pinched nerve?

1. A sprain or strain?

1. Swelling or pain in muscles, tendons, bones or joints?

1. Do you get frequent muscle cramps when exercising?

1. Dislocated joint(s)?

1. Upper or lower back pain?

1. Fracture(s), stress fracture(s), or broken bone(s)?

1. Do you wear any protective braces or equipment?

1. Are you missing limbs or do you have any artificial limbs?

If you answered YES to any of the above questions, please explain further (include relevant dates):

______

______

______

Have you ever had, or do you currently have any of the following general or exercise related conditions…

1. Exercise-induced asthma?

1. Coughing, wheezing or shortness of breath in weather changes?

1. Become tired more quickly than others?

1. Viral infections (i.e.: mono, hepatitis, coxsackie virus)?

1. Any of the following skin conditions: cold sores/herpes, impetigo, MRSA, ringworm, warts, sun sensitivity? Please note which one(s) below.

1. Weight gain/loss (of 10 pounds or more) within the last year?

1. Ever have an eating disorder?

1. Ever have a substance abuse problem?

1. Ever have depression, anxiety, or other psychological disorder?

1. Heat-related problems (dehydration, dizziness, fatigue, headache, heat exhaustion, heat stroke, muscle cramps)? Please note which one(s) below.

1. Absence or loss of an organ (i.e.: kidney, eyeball, spleen, etc.)?

If you answered YES to any of the above questions, please explain further (include relevant dates):

______

______

______

CERTIFICATION – IMPORTANT – PLEASE READ BEFORE SIGNING

I certify under penalty of perjury that the information I have entitled on this application is true and complete to the best of my knowledge. I further understand that any false, incomplete, or incorrect statements may result in my disqualification or dismissal from the program. I authorize all agencies to release any information they may have concerning the information provided on this application.

______

Applicant’s SignatureDate

PERMISSIONS

WAIVER & RELEASE

In consideration for permission to participate in the Physical Activity (“EVENT”) held on the MiraCosta Community College District (“DISTRICT”) property or associated with a prior pre-arranged off-site location with instruction conducted by district staff, the person signing below hereby stipulates and agrees:

Assumption of Risk

I represent that I am physically sound and to my knowledge I have no medical condition that will prevent me from participating in the EVENT. I VOLUNTARILY AND FULLY CHOOSE TO ASSUME ALL RISKS AND DANGERS, including the risk of injury or death, that may be associated with, or resulting from, my participation in the EVENT.

Release from Liability

I agree for myself and for my heirs to fully and forever discharge and release the MiraCosta Community College District, MCC Foundation, its respective trustees, officers, employees and agents (collectively, the “Releasees”) from any and all liabilities, claims, demands, actions and causes of action whatsoever whether known or unknown based upon any injuries, costs, loss of service, expenses, actions and causes of action whatsoever whether known or unknown based on any injuries, costs, losses of services, expenses and any and all damages, claims whatsoever, whether caused by their negligence or for any other reason, on the account of, or in any way resulting from, personal injuries, conscious suffering, death or property damage to myself or to any other person or property, in any way connected with my preparation or participating in the EVENT. I agree that this Liability Release and Waiver Agreement shall include my participation in any and all activities sponsored by the Releasees including, but not limited to, participation in instructional sessions, or any physical activity.

Covenant Not To Sue

I agree for myself and for all my heirs, not to sue Releasees, not to initiate or assist the prosecution of any claim for damages or cause of action which I or my heirs may have by reason of personal injury or death to participation or damage or destruction to participant’s property arising from Releasees activities.

Indemnity Agreement

I agree for myself and my heirs to indemnify and hold harmless the Releasees from any loss, claims, actions, causes of action or proceedings of any kind which may be initiated by me or by any other person, entity or organization, including demands, judgments, costs, losses of service, expenses, or reimbursement of counsel fees incurred by participant or by the Releasees from activities contemplated by this Agreement. I give permission to Releasees to obtain on my behalf any emergency medical treatment. In case of sickness, accident or injury, Releasees may have my express permission to secure, at my expense, such medical treatment as is deemed necessary in the sole discretion of Releasees.

Continuation of Obligations

I agree for myself and my heirs that the above provisions, including Assumption of Risk, Release from Liability, Covenant Not To Sue and Indemnity Agreement, shall continue in full force and effect now and at all future times when participant is involved in any physical activity relating to a District sponsored event.

I HEREBY ACKNOWLEDGE THAT I HAVE FULLY READ EACH OF THE ABOVE PROVISIONS AND FULLY UNDERSTAND AND AGREE WITH EACH PROVISION. I HEREBY EXPRESSLY WAIVE THE PROVISIONS OF CALIFORNIA CIVIL CODE SECTION 1542 WHICH PROVIDES AS FOLLOWS:

A general release does not extend to claims which the creditor does not know or suspect to exist in his or her favor at the time of executing the release, which, if known by him or her, must have materially affected his or her settlement with the debtor.

I hereby understand and agree that all rights under section 1542 of the California Civil Code are expressly waived and that this release releases all injuries, damages, or losses to the person and property, real or personal, whether known or unknown, foreseeable, unforeseeable, patent or latent, which she/he may have against another party or parties herein released.

I hereby acknowledge that I have fully read the District and Department policies and procedures and fully understand and agree with each provision. (initial)

RELEASE & DISCHARGE

As a condition of my participation in a field trip or excursion, I understand that California Education Code Section 35330(d), provides that “all persons making the field trip or excursion shall be deemed to have waived all claims against the District or the State of California for injury, accident, illness or death occurring during or by reason of a field trip or excursion. All adults taking out-of-state field trips or excursions and all parents or guardians of students taking out-of-state field trips or excursions shall sign a statement waiving such claims.” Participant agrees to release and discharge (agreeing to make no claim and not to sue) the State of California or the District (it’s Board of Trustees, officials, employees, agents) (“Released Parties”) from all claims of injury or loss which the participant or the minor participant for whom parent or legal guardian signs for, may suffer, arising in whole or in part from the Participant’s enrollment or participation in the excursion, including but not limited to any injury, accident, illness, or death or any loss or damage to personal property occurring during or by reason of the participation in said excursion.

RULES & REQUIREMENTS

Obey and uphold any and all rules and requirements of the program; observe the designated schedule and follow the instructions given by District supervisory personnel in all matters pertaining to the program.

I grant the District, acting by and through the personnel designated to supervise said excursion, the right to terminate my participation in the program if it is determined by them that my continued participation is detrimental to or in conflict with the purpose of the excursion, or is not in harmony with the best interests of the other participants and/or supervisory personnel. I grant the right to terminate my participation in the program if it is determined that my conduct is detrimental to the best interests of the group. Either scenario will result in my return home, at my personal expense. No refund or fees will be given.

Violation of any of the stated rules or regulations pertaining to this course will result in my immediate removal from the program.

DRUG & ALCOHOL STATEMENT

Use, possession, sale, distribution, or manufacture of, or the attempted sale, distribution, or manufacture of alcohol and drugs, including controlled substances, on District properties or at official sponsored District functions is unlawful or otherwise prohibited by District Board of Trustees Policies 3550 & 3560.

______

Applicant’s SignatureDate

Any questions about the waiver and release should be discussed between you and your legal representative or attorney.

If you have any questions or concerns about the remainder of this form, please contact Christine Jensen at 760.795.6822 or . Once this form has been completed, please submit it (and relevant paperwork) in one of the following ways:

1. Scan and email it to
2. Fax it to Community Services at 760.795.6826
3. Mail it:MiraCosta Community Services

1 Barnard Drive, M/S 4

Oceanside, CA 92056

1. Drop it off: MiraCosta Community Services

1 Barnard Drive (Bldg 1000, Administration)

Oceanside, CA 92056

Mon-Thurs: 9am-5pm

Fri: 9am-4pm