HPD Law Enforcement Explorer Program Application

Honolulu Police Department

Law Enforcement Explorer Program
Disclaimer

All information provided in this form is used for required background checks conducted by sworn HPD LEEP staff. This background check process is mandatory.
Applicant information
Applicant Name*

First NameLast Name
SSN last 4 digits
Birth Date*

MonthDayYear
Age
Gender
Shirt Size
Belt size
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Education
Current grade / level of education*

9th grade10th grade11th grade12th gradCollege StudentNo school
Name of School
Parent's Information
Father / Guardian 1 Information

First NameLast Name
Birth Date

MonthDayYear
Same as applicant
Father's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father / Guardian 1 Phone

Area CodePhone Number
Father / Guardian 1 Email
example@example.com
Mother / Guardian 2 Information
Mother / Guardian 2 Name

First NameLast Name
Birth Date

MonthDayYear
Same as applicant
Mother Guardian 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mother / Guardian 2 Phone

Area CodePhone Number
Mother / Guardian 2 Email
example@example.com
Medical History
1. Are you currently taking any medications?

YesNo
If yes, please explain?
2. Are you allergic to any medication, foods, plants, insect toxins or anything not mentioned?

YesNo
If yes, please list your allergies?
Family Physician
Medical Insurance
Policy Number
Arrest / Criminal
1. Have you ever had any contact with Law Enforcement officials?

YESNO
2. Have you ever been charged with a crime?

YESNO
3. Have you ever received a citation from a Law Enforcement Official?

YESNO
5. Have you ever consumed alcohol?

YESNO
If yes, please list the last time you consumed alcohol.
6. Have you ever consumed an illegal narcotic or unprescribed medication

YESNO
List any illegal narcotic or unprescribed medication you have ever taken, and the last time you consumed it.
Additional explanation for questions 1-6:
How did you hear about the Law Enforcement Program?
Affirmation Statement
Please read the following statement and sign prior to submitting this questionnaire.

I affirm that this questionnaire contains no misrepresentation or falsifications, omissions, or concelaments of material fact, and that the information given by me is true and complete to the best of my knowledge and belief. I am aware that statements made by me on this questionnaire are subject to later investigation. I am further aware that should any investigation disclose any misrepresentation, falsification, omission, or concealment or material fact, my application may be rejected and I will not be eligible to become an Explorer with the Honolulu Police Department. If I have already been accepted I may be dismissed.

I authorize the Honolulu Police Department to make inquiry of references listed on the questionnaire regarding my integrity, reputation, and character.

I realize that it is necessary for the Honolulu Police Department to thoroughly investgate all aspects of my personal background and qualifications. By applying to be a volunteer with the Honolulu Police Department Explorer Post, I expressly waive all my legal rights and causes of action to the extent that the Honolulu Police Department Investigation (for purposes of evaluating my suitability) may violate or infringe upon these aforementioned legal rights and cause of action of mine.
Applicant Name
Check if 18 or older
Signature

Powered by Jotform SignClear
Parent / Guardian Name
Signature

Powered by Jotform SignClear
Medical Treatment & Release of Liability Form
I, Parent Full Name (Parent or Guardian / Self), give my permission to have dependent / self, (full name)AFull Name, date of birth (MM/DD/YY) DOB , Address Street address Address line 2, City, State, Phone (Area code) phone number.
Treated at the most available medical facility, in the event said dependent becomes ill or injured. I understand I am responsible for ALL the cost of any treatment.

As the parent/guardian or Explorer adult over 18 (self), I authorize my son / daughter / self to participate in explorer activities sponsored by the Honolulu Police Department. This authorization acknowledges certain dangers may occur, including, but not limited to, the hazards of strenuous physical exercises, mock scene participation, and any other duty or circumstances associated with events and / or training.

In consideration of and by authorization of my son / daughter / self, the right to particpate in such events or other activities and the services, training and food arrangements for my son / daughter / self, by the Explorer Advisors, the Honolulu Police Deaprtment, and the Boy Scouts of America: Aloha Council / Learning-for-Life, I have and do hereby assume the above mentioned risks and will hold them harmless from any and all liability, action and cause of action, debts, claims, demands of every kind and nature whatsoever, which may arise from my participation in or my going to and from any activities arranged for me by the aforementioned parties.

I have adequate insurance coverage through my family to cover my medical needs should I become ill or injured, and understand I must fully bear the cost of such treatment through such coverage. The terms here of shall serve as a release and assumption of risk for my heirs, executors and administration and for all members of my family.

As a parent, legal guardian, or self, I understand the aforementioned and acknowledge so by signing this form. I swear the information contained on this form, which I have provided, is complete and accurate to the best of my knowledge.
Parent / Guardian Signature (If under 18)

Powered by Jotform SignClear
Date

MonthDayYear
Date
Explorer Signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
Photograph / Video Recording Release Form
I hereby give my permission to the Honolulu Police Department (HPD) to videotape, or otherwise record my name, voice, and/or person.

I understand that these recordings of me will be used exclusively for non-commercial purposes to highlight the programs of the HPD Police Activities Leagues (PAL), which may include open-circuit (broadcast), closed circuit, and/or cable television transmission within or outside the State of Hawaii in perpetuity, including the internet.

I waive my rights to inspect any film, audiotape, photograph, or the likeness or finished production to be used for information or broadcast purposes.

I also understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback, and that HPD is not responsible for any expense or liability incurred as a result of my participation in this recording, including medical expenses due to any sickness or injury incurred as a result.

HPD may also use my name, likeness and/or bibliographical identification for publicizing and promoting the use of these recordings.

I release the City and County of Honolulu, the Honolulu Police Department, and their officers, agents and employees, and their successors from any and all claims whatsoever, including without limitation, and all claims of libel, invasion of privacy, or infringement of publicity rights in connection with the use of my name, my likeness, or my voice as above described.
Parent / Guardian name
Parent / Guardian signature

Powered by Jotform SignClear
Date

MonthDayYear
Date
To be completed by staff following application review
Advisor signature
Should be Empty:

Honolulu Police Department

Disclaimer

Applicant information

Education

Parent's Information

Mother / Guardian 2 Information

Medical History

Arrest / Criminal

Affirmation Statement

Medical Treatment & Release of Liability Form

Photograph / Video Recording Release Form

To be completed by staff following application review