Certified Armed Protection Specialist and High Threat Protection Specialist
Application Form
[ ] Certified Armed Protection Specialist
Anticipated Date of Attendance: __________
[ ] High Threat Protection Specialist
Anticipated Date of Attendance: __________
ENROLLMENT INFORMATION (Please print clearly)
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
Email: ______________________________________________________________________________
Phone: _________________________________
Date of Birth:
SS#:
[ ] Active Duty
_________________________________
__________________________
[ ] Veteran
[ ] Civilian
PAYMENT INFORMATION (please attach authorization form if applicable)
[ ] Cash or Check
[ ] Grant (must be approved) [ ] TA Funding
[ ] VRAP
[ ] GI Bill Funding – Montgomery. % Benefits: _____ [ ] GI Bill Funding – Post 9/11. % Benefits: _____
If you are not 100% covered, please indicate how you will pay the difference.
[ ] Credit Card – Card #: ________________________________________
Exp.: _______________
Name on Card: ___________________________________________________________
[ ] Other: _____________________________________________________________________________
CRIMINAL HISTORY
In order to handle weapons during this course and to be hired for a security/protection position,
students must have certain legal qualifications. Please answer the questions below to help us determine
if you are eligible for our program.
1. Have you ever been convicted by any court of a misdemeanor crime of domestic violence?
[ ] YES
[ ] NO
2. Have you ever been convicted by any court of a felony?
[ ] YES
[ ] NO
3. Is there anything in your criminal, medical or physiological history that would prevent you from
handling firearms according to US federal, state or local laws?
[ ] YES
[ ] NO
If you answered YES to any of these questions, even if charges were dismissed, deferred or changed,
please explain each charge fully (if you need to attach additional sheets, please do so):
_____________________________________________________________________________________
_____________________________________________________________________________________
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PROOF OF CITIZENSHIP
In order to enroll in this program, students will need to provide proof of citizenship or legal residency.
The following forms of identification are acceptable (please choose two forms of ID, copy and attach):
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Driver’s License
US Military ID card or report of Separation (military discharge)
Social Security Card
Birth Certificate showing birth in the US, American Samoa, D.C., Guam, Northern Mariana
Islands, Puerto Rico, Swains Islands or US Virgin Islands
US Passport (unexpired)
Alien Registration Receipt Card (green card) or Resident Alien Card (green card). These must
contain a photograph of the bearer.
Certificate of Naturalization. This must contain a photograph of the bearer with a dry seal over
the photograph.
US Citizen Identification Card. Must contain photo & physical description.
Identification Card for use of Resident Citizen in the US
Certificate of US Citizenship or Certificate of Birth abroad issued by the Department of State
EMERGENCY CONTACT INFORMATION
Name (print):
________________________________________________________________________
Address:
________________________________________________________________________
Email: ______________________________________________________________________________
Phone: _________________________________
Relationship:
__________________________
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-thecounter 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 Signature
__________________________
Date
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HEALTH INFORMATION
This information will be kept confidential. It is for qualification purposes only and will not be shared with
anyone 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…
[ ] YES [ ] NO 1. Restriction from sports/PT for a health related problem?
[ ] YES [ ] NO 2. An injury or illness since your last physical exam?
[ ] YES [ ] NO 3. A chronic or ongoing illness (such as diabetes or asthma)?
[ ] YES [ ] NO 4. Surgery, hospitalization, or any emergency room visits?
[ ] YES [ ] NO 5. Any allergies to medications?
[ ] YES [ ] NO 6. Any allergies to bee stings, pollen, latex or foods? If yes, please explain below
(also indicate medication you take for allergic reaction)
[ ] YES [ ] NO 7. Any anemias, blood disorders, sickle cell disease/trait, bleeding tendencies or
clotting disorders?
[ ] YES [ ] NO 8. A blood relative who died before age 50?
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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…
[ ] YES [ ] NO 9. Concussion or head injury?
[ ] YES [ ] NO 10. Memory loss?
[ ] YES [ ] NO 11. A seizure?
[ ] YES [ ] NO 12. Frequent or severe headaches (with or without exercise)?
[ ] YES [ ] NO 13. Fuzzy or blurry vision?
[ ] YES [ ] NO 14. Sensitivity to light/noise?
[ ] YES [ ] NO 15. 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…
[ ] YES [ ] NO 16. Restriction from sports/PT for heart problems?
[ ] YES [ ] NO 17. Chest pain or discomfort?
[ ] YES [ ] NO 18. Heart murmur?
[ ] YES [ ] NO 19. High blood pressure?
[ ] YES [ ] NO 20. Elevated cholesterol level?
[ ] YES [ ] NO 21. Heart infection?
[ ] YES [ ] NO 22. Dizziness or passing out during or after exercise without known cause?
[ ] YES [ ] NO 23. Has a provider ever ordered a heart test (EKG, echocardiogram, stress test, etc.)?
[ ] YES [ ] NO 24. Racing or skipped heartbeats?
[ ] YES [ ] NO 25. 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…
[ ] YES [ ] NO 26. Vision problems? Please note below whether you wear contacts, eyeglasses, or
protective wear.
[ ] YES [ ] NO 27. Hearing loss or problems? Please note below whether you wear hearing aides or
implants.
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[ ] YES [ ] NO
[ ] YES [ ] NO
[ ] YES [ ] NO
28. Nasal fractures or frequent nose bleeds?
29. Wear braces, retainer or protective mouth gear?
30. 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…
[ ] YES [ ] NO 31. Numbness, a “burner”, “stinger” or pinched nerve?
[ ] YES [ ] NO 32. A sprain or strain?
[ ] YES [ ] NO 33. Swelling or pain in muscles, tendons, bones or joints?
[ ] YES [ ] NO 34. Do you get frequent muscle cramps when exercising?
[ ] YES [ ] NO 35. Dislocated joint(s)?
[ ] YES [ ] NO 36. Upper or lower back pain?
[ ] YES [ ] NO 37. Fracture(s), stress fracture(s), or broken bone(s)?
[ ] YES [ ] NO 38. Do you wear any protective braces or equipment?
[ ] YES [ ] NO 39. 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…
[ ] YES [ ] NO 40. Exercise-induced asthma?
[ ] YES [ ] NO 41. Coughing, wheezing or shortness of breath in weather changes?
[ ] YES [ ] NO 42. Become tired more quickly than others?
[ ] YES [ ] NO 43. Viral infections (i.e.: mono, hepatitis, coxsackie virus)?
[ ] YES [ ] NO 44. Any of the following skin conditions: cold sores/herpes, impetigo, MRSA,
ringworm, warts, sun sensitivity? Please note which one(s) below.
[ ] YES [ ] NO 45. Weight gain/loss (of 10 pounds or more) within the last year?
[ ] YES [ ] NO 46. Ever have an eating disorder?
[ ] YES [ ] NO 47. Ever have a substance abuse problem?
[ ] YES [ ] NO 48. Ever have depression, anxiety, or other psychological disorder?
[ ] YES [ ] NO 49. Heat-related problems (dehydration, dizziness, fatigue, headache, heat
exhaustion, heat stroke, muscle cramps)? Please note which one(s) below.
[ ] YES [ ] NO 50. 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):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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PHYSICAL FITNESS REQUIREMENT
Course participants must be able to perform the physical requirements associated with protection
duties and be able to lift and carry irregular shaped items weighing up to 75 pounds, including up and
down steps, stairs, into and out of vehicles. Requires standing, walking, and/or sitting in vehicles for long
periods of time, in all weather conditions. This training requires that participants engage in intermittent
sitting, walking, running, squatting, stretching, bending, and kneeling.
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 Signature
PERMISSIONS
[ ] YES [ ] NO
[ ] YES [ ] NO
__________________________
Date
I grant permission that any pictures or videos taken may be used for future
promotional purposes.
I agree to be tasered as part of the course (CAPS program only).
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
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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.
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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 Signature
__________________________
Date
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 cjensen@miracosta.edu. Once this form has been completed, please submit it (and relevant
paperwork) in one of the following ways:
1.
2.
3.
4.
Scan and email it to cjensen@miracosta.edu
Fax it to Community Services at 760.795.6826
Mail it:
MiraCosta Community Services
1 Barnard Drive, M/S 4
Oceanside, CA 92056
Drop it off:
MiraCosta Community Services
1 Barnard Drive (Bldg 1000, Administration)
Oceanside, CA 92056
Mon-Thurs: 9am-5pm
Fri: 9am-4pm
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