Suny Canton 20 Police Academy Registration

SUNYCANTON 20_ POLICEACADEMY REGISTRATION/ BILLING FORM · JastName: ----------- First:__________ Middle Initial:_ . _. ) , od a I .Security#: _________ _ Date of Birth:-------------~ •. -Street Address:_____________ City, State, Zip:____________ _ · Home Phone: __________ _ Cell Phone: --------------- . / Pdlite Agency Name:--------------- Sheriff/Chief:--------- .,Sheriff/ Chief's Departmental Phone: _______________ -'---------- P:pliceAgency's Street Address: _________________________ _ City: _______________ State: __________ Zip:_____ _ . · Academic Credit - Do you expect credit on your SUNYCanton College transcript for the police academy? · Yes or No:---- . {lt°yes; you must be admitted to SUNY Canton before registration can be completed. Usual college tuition and ·fees will apply). · L~i"~/EqupimentFee (LBEQ) $300.00 /$500 $___ _ Out of County Police Officer Fee (PATU) $1,200.00 $___ _ . · :Parking and Registration Fee for Personal Vehicle $48.50 (part time student, $98 full time)$ ___ -'-'- SU,NYCanton Fitness Center $75.00 (for non-credit students only) $___ _ ;}>r e-Employment Participant (non police officer) Yes or No:____ _ Total:$ ---- Police Academy Director's Approval (directors signature):--------- Date:----- STUDENTSERVICE CENTER USE ONLY Full or Part Time Student: Curr/Degree _______________------------ _ WAIVER OF LIABILITY I, the undersigned participant, understand and acknowledge that I am participating in the DAVID SULLIVAN/ ST. LAWRENCECOUNTY LAW ENFORCEMENTACADEMY at SUNY Canton University, located at 34 Cornell Drive, Canton, New York and that I realize that all parties involved in this training course carry no insurance against injury for any participants . I understand and acknowledge that serious personal injury or death is a possibility and I understand and acknowledge that any injury or death to me will be my full financial responsibility and will have to pay for any and all injuries that may occur during my training in this academy. I hereby release, indemnify, and forever discharge and hold harmless, Albert Duquette, S.U.N. Y. Canton College, instructors, and any other participants, from any and all responsibilities and claims for personal injury, death, legal actions or suits, damages or losses of any kind or description, both at law or in equity arising out of or in any way connected with any of the above mentioned David Sullivan/ St. Lawrence County Law Enforcement Training. IN WITNESS WHEREOF, I have set my hand to seal this document, which I intend to be a legally binding document, on the day and year below written and understand it fully. Date: -------------- Sworn before me, this _____ _ PRINTED NAME: ________ _ day of __________ _ Signature: ____________ _ Notary Signature POLICE ACADEMY STUDENT REGISTRATION FORM SPRING 20_ SEMESTER Full Name: __________________ Social Security#/ Student ID#: _______ _ Maiden/ Previous Name: Birth Date:__________ _ Home Phone #:________ Cell Phone#: ________ Email:____________ _ Street & Address: State: Zip:____ _ Mailing Address: State: Zip:____ _ Are You? Male:__ or Female: ___ / Are you a New York State Resident?_____________ _ Have you ever taken a course offered by SUNYCanton? If yes, year & semester:_________ _ Have you ever attended another college? __ If yes, what college?--------------~--- High School attended: Year of High School Graduation or GEDawarded: ___ _ Have you ever been convicted of a Felony? _____ _ Have you ever been dismissed from college for disciplinary reasons?_________________ _ Do you wish to restrict the release of your address, phone number and other directory information: ___ _ Are you a U.S. Citizen: __ If no, provide your home country address: ______________ _ Ethnic Code - Optional: White/Non-Hispanic: __ Black/Non-Hispanic: __ Asian/Pacific Islander: __ American Indian/Alaskan: American Indian/Alaskan Other: ____________ _ Police Academy Applicants skip to the bottom (signature, social security# and date) __ Auditing: (Hired full or part time Police Officer not purchasing the pre-employment 6 credits) __ Part-time non-degree and hired (police officer deciding to purchase the pre -employment 6 credits, their agency is billed for everything except the credits . The student is billed for the credits) __ A degree student completing course as part of a internship (college student completing their degree) __ Part-time non-degree paying out of pocket (non-students taking the pre -employment 6 credits) __ Part-time non degree paying out of pocket/ hired (part time police officer who is paying for the academy and opted to purchase the 6 pre-employment credits. Their agency pays for nothing and this student is responsible for all bills). I CRN COURSENUMBER SECTIONNUMBER COURSETITLE CREDITHOURS I I I I When Paying: Students will be considered officially registered upon receipt of tuition and fees payment. REGISTRATIONCERTIFICATION : I certify that this form with my signature will constitute my registration at SUNY Canton for the above mentioned semester. Signature: ______________ _ Student Social Security#/ ID:-------------- Date: ---------- Police Academy Director 's Approval (directors signature): ___________ Date :_____ _ / s y Course Audit* Form CANTON *Subjectto available space Instructions: Fill out all requiredinformation below. Please print. Definition of Auditor -Any individualwishing to attend a credit-bearingcourse , but choosingnot to receive credit'-'or formalrecognition for their participation. *C1·editwill 11otbe gra11te,l011ce a st11de11thas committed to course audit process. StudentName: --------------------- MaidenName :---------- Address:- scr-ee_c______________ c_it)-'/to-11-,n--------------- sca-ce--- z-ip__ _ Phone:-------- SUNYCanton ID /SSN Dateof Birth:------ Sex: M F Haveyou everbeen convictedof a felony(circle one) No Yes Haveyou ever been dismissedfor disciplinatyreasons from a college(circle one) No Yes StuclentSignature---------------------------------- Semester: FALL WI NTER SPRING SUMMER YEAR---- CourseNumber Section CourseName Instructor Signature:_____________ _ InstructorName :------------- Conditions:(To be agreed upon by student and instructor) ________________ _ AuditFee : $50 StudentService Center Signature: ----------------- SeniorCitizen Waiver : No audit fee for stude11tsage 60 a11dover. SpecialCircumstances Fee Waiver: -------V-P~f o-rA -ca-de-m-ic-AIT~a-irs______ _ Dace DescribeSpecial Circumstances :------------------------------ Submit completed.formto Registrar.French Hall 105, b1forefirstclass. DISTRIIlUTION: W1111E- REGISTRAR C,~'IARY- SCI IOOL01:,1 N P11'K- INSTRUCTOR Gow - STUDE1'T RE\%ED 4/08 PERSONAL INFORMATION - Please print clearly I NO NICKNAMES PLEASE NOTE: There is a $10 replacement charge for lost cards Last Name _________________ First Name _____________ Initial Mailing Address .___________________________________ _ City __________________ State ____ Zip _____ Phone _______ _ Gender D M D F Date of Birth __________ (Seniors/Youth: Proof of Age required) Age __ Physician ____________ Emergency Contact.__________ Phone _____ _ **For notification of closures, holiday hours, class schedules and notice of renewal dates** Email ____________________ _ FAMILY MEMBERSHIP INFORMATION- Please print clearly** {GO TO NEXT PAGE IF N/A} ** If applying for a family membership, please provide information for each authorized immediate family member. Each family member over the age of 14 must fill out separate application forms. Immediate family is identified as spouse and children ages 21 and under. Children over 21 are valid only if HR has determined they are covered under the family insurance policy. Name __________________ Age __ _ Date of Birth ______ _ Name __________________ Age __ _ Date of Birth ______ _ Name __________________ Age __ _ Date of Birth ______ _ Name __________________ Age __ _ Date of Birth ______ _ FOR OFFICIAL USE ONLY INITIAL TERM: __ / __ / __ to __ / __ / __ [=:J SUNY Canton Student AMOUNT: ------------ CJ SUNY Canton Faculty/Staff STAFF INITIALS : [=:J SUNY Canton Retiree Spouse/Dependent of F/S/R - DEPENDANT OF:------------------ Alumni Year of Graduation:--------- CJ Adult (14-59} FORMSOF PAYMENTACCEPTED: CJ Senior (60+} CASH, CHECK,CREDIT CARD CJ State Employee **Banner ID (barcode scanner) - CJ Family Primary ** Social Security# - ---------- [=:J Family Dependant ** IOS#- ---------- DEPENDANT OF: ______________ _ PHYSICAL ACTIVITY READINESS QUESTIONNAIRE (PAR-Q) PAR-Q is designed to help you help yourself. Many health benefits are associated with regular exercise, and the completion of PAR Q is a sensible first step to take if you are planning to increase the amount of physical activity in your life. For most people physical activity should not pose any problems or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Common sense is your best guide in answering these few questions. Please read them carefully and check YES or NO opposite the question if it applies to you. If yes, please explain. 1. Has your doctor ever said you have heart trouble? Yes,--------------------------------- 2. Do you frequently have pains in your heart and chest? Yes,--------------------------- - ------ 3. Do you often feel faint or have spells of severe dizziness? Yes,---------------------------------- 4. Has a doctor ever said your blood pressure was too high? Yes,---------------------------------- . 5. Has

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