Last Name *

Middle Name

First Name *

Sex *

Maiden name (s) or other names used.

Date of Birth *

Age *

Last four digits of your SSN *

Where were you born? City, State & Country *

Current Address *

Address Line 1

Address Line 2

City

State

Zip Code

County of Residence *

Mailing Address (if different than physical)

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone Number *

Work Phone Number *

Cell Phone or Messaging Number *

Email Address *

Emergency Contact Information

Emergency Contact Name *

First

Last

Relationship *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone Number *

Work Phone Number *

Cell Phone Number *

Background Information

High School Education *

City/State *

GED/HiSET, location received *

Date received

College education

Hours and degree earned

Major

Date graduated or last attended

Notice of Testing for Illegal Drug Use

I acknowledge that the profession of a law enforcement officer requires its members to be held to a high standard and obey the laws of the state of Missouri and the United States of America. As a prospective member of this profession I know that the use of illegal drugs and/or medications not currently prescribed to me is against the law. I am signing this form with the knowledge that I will be tested for the presence of illegal drugs and/or medications not currently prescribed to me in my body (urine) during the academy. I hereby give my consent for the Drury University Law Enforcement Academy to have my urine tested for such drugs and/or medications knowing if any drug is detected I will be terminated from the academy.

If a student tests positive for illegal drugs and/or medications he/she will have the option of medically withdrawing from the academy to seek treatment. The student will be responsible for expenses incurred during the academy including the entire academy fee. Upon successful treatment the student will be allowed to reapply for future academies at Drury University without prejudice.

By checking this box, I agree.

Waiver for Release of All Liability and Assumption of Risk

I hereby waive, release and forever discharge the Drury University Law Enforcement Academy, its agents, representatives, heirs, executors, administrators, successors and assigns, of and from any and all claims, demands, rights and causes of action rising from and any and all foreseen and unforeseen physical and mental injuries sustained by me during all self-defense, physical training, role playing, firearms, driver training or other activities I participate in during the Academy sessions. This agreement is legally binding upon me, my heirs, executors, administrators and assigns.

I am presently in good physical and mental health.
I have no reason to believe that I am not in good physical and mental health.
I am capable of strenuous physical activity.
I am fully aware of, acknowledge and assume all risk of injury during my participation in this training.
I have read and fully understand the terms and conditions of this agreement and sign it voluntarily.

Authorization for Release of Drury University Records

I authorize the Drury University Law Enforcement Academy to release any and all information, including test scores, attendance, disciplinary actions, and any other records pertaining to the academy contained in my academy file(s) to any law enforcement agency.

Grizzly Industrial Voluntary Release, Waiver of Liability and Indemnity Agreement

PLEASE CAREFULLY READ THE FOLLOWING VOLUNTARY RELEASE, WAIVER OF LIABILITY, AND INDEMNITY AGREEMENT (“INDEMNITY AGREEMENT”) BEFORE SIGNING.

I seek the opportunity to further my Law Enforcement Training through Drury University law enforcement training and understand some of the training will be conducted on property owned by Grizzly Industrial.

I intend to release Drury and Grizzly Industrial (referred collectively as “Releasees”) from any such claims or causes of action, by whomever asserted, and I do so by this document. I intend for the document to be given the widest possible application.

Having had the opportunity to consult with counsel or other advisers of my choice, on my own behalf and on behalf of my personal representative, heirs, spouse, successors, or assigns:

1. I AGREE TO HOLD HARMLESS, RELEASE, DEFEND, AND INDEMNIFY Releasees and/or any other person or entity with an interest in Releasees from any and all liability and/or claims, demands, actions, executions, judgments, or liability, present or future, which I may have against Releasees or any other person or participant for any foreseen or unforeseen bodily and personal injuries and/or property damage, including but not limited to injury and/or damage to personal property and/or chattels, and the consequences arising from, or to arise from, any accident, casualty, or event occurring from any cause whatsoever during my participation in Law Enforcement Training and any related activity, including but not limited to any act of negligence, and any failure to act of Releasees, or any other person or participant, or from the condition of Releasees’ facilities and/or equipment. I hereby covenant to hold Releasees harmless and indemnify Releasees from any claim, demand, causes of action, action, execution, judgment, liability, or expense, present or future, that may arise out of my participation in Law Enforcement Training and any related activity, whether caused by Releasees or otherwise, and no matter by whom asserted.

2. I UNDERSTAND that my participation in Law Enforcement Training and any related activity is potentially hazardous and contains danger and risks. I appreciate and voluntarily elect to accept and assume all danger and risks associated with my participation in Law Enforcement Training and any related activity.

3. I UNDERSTAND that in the case of an emergency, every effort will be made to secure proper treatment for me. I hereby give permission for such treatment. I hereby agree to hold harmless, release, indemnify, and defend Releasees and each of their officers, directors, shareholders, members, agents, managers, employees, instructors, and leaders from any claim, demand, action, execution, judgment, liability, or expense, present or future, that may arise out Releasees’ selection or authorization for treatment of any medical provider.

4. I REPRESENT that my personal health and/or accident insurance covers any accident or illness which I may incur during Law Enforcement Training and any related activity. I personally guarantee payment of any cost or other liability arising out of any such accident or illness.

5. I ACKNOWLEDGE that no oral representation or inducements have been made to me to sign this document. No release of any provision of this document has been made to me and I understand and agree that none would be effective.

6. I AGREE that this document is intended to be as broad and as inclusive as permitted by the laws of the State of Missouri. If any portion of this document held invalid, I agree that the balance shall, not withstanding the partial invalidity, continue in full legal force and effect.

7. I AFFIRM that I am of lawful age and legally competent to sign this legal document, that I understand that its terms are contractual and not a mere recital, that I have signed this document as my own free act and deed, and that it is binding upon my heirs, successors, and assigns. This document shall be construed according to the laws of the State of Missouri.

I HAVE READ THIS VOLUNTARY RELEASE, WAIVER OF LIABILITY, AND INDEMNITY AGREEMENT. I UNDERSTAND IT IS A RELEASE OF ALL CLAIMS, I UNDERSTAND I ASSUME ALL RISK OF PARTICIPATION. I VOLUNTARILY AFFIRM THE ABOVE PROVISIONS.

Peacekeepers Training, 21st Century Peacekeeprs LLC, Peacekeepers Investments LLC Release of Liability/Assumption of Risk

The defensive tactics training program involves use of physical force training that involves simulated and full contact defensive tactics techniques. The risk of injury including permanent injury or death does exist.

The range training program includes the use of live fire lead ammunition for both pistol and shotgun. The risk of injury including permanent injury or death does exist.

I, for myself and on behalf of my heirs, hereby release Peacekeepers Training, 21st Century Peacekeepers LLC, Peacekeepers Investments LLC, Drury University, their agents, their officers, course instructors and sponsors for any liability resulting from my participation in the course or courses provided by Peacekeepers Training LLC or 21st Century Peacekeepers LLC or at any facility owned by Peacekeepers Investments LLC.

I understand and agree that this release of liability covers all training sessions in which I participate or attend.

I have fully read and understand this assumption of risk and release of liability agreement. I have been given an
opportunity to ask questions with regard to this agreement.

I hereby agree to the above.

Registration Agreement

I understand that I will be responsible to Drury University for any and all charges incurred as part of my course registration for the current semester. I am aware of the Drury University class refund policy. I realize that my financial obligation is not changed if I drop classes after the refund dates. Refund dates are available by accessing the Academic Calendar.

I authorize Drury University to use monies from federal funds, grants, loans, and other to pay tuition, fees, bookstore charges, interest and fines and acknowledge that a change in my schedule may affect any financial aid or VA benefit awards. I agree to pay 1% interest per month (12% per annum) on the unpaid balances, plus legal fees and collection costs. I understand that I will be responsible to the University for any and all charges incurred as part of my course registration for the current semester. I recognize this obligation does not change if I drop coursework after the refund dates above. I am aware that if I do not officially withdraw from courses I am not attending I will receive a failing grade.

I am aware that if I am unable to complete any of the required training for any reason, I will have to complete that portion or portions of the academy with another academy class. I understand that I will be responsible for the additional tuition and fees and may or may not be eligible for Financial Aid for that class or classes.

I acknowledge that it is my responsibility to check my Drury University email account on a regular basis as it is considered the University’s official mode of communication. Students corresponding by email in reference to adding/dropping classes or financial aid related matters must use their official university email account (i.e.@drury.edu) and include full name and Drury ID number. All responses from the University will be sent to your official University email address.

By checking this box, I agree.

Upon submission you will receive an email with additional forms that are required to be completed. Please complete these additional forms, print on white paper, and have them notarized. Additional instructions are included.

Drury University Law Enforcement Academy Application

Emergency Contact Information

Background Information

Notice of Testing for Illegal Drug Use

Waiver for Release of All Liability and Assumption of Risk

Authorization for Release of Drury University Records

Grizzly Industrial Voluntary Release, Waiver of Liability and Indemnity Agreement

Peacekeepers Training, 21st Century Peacekeeprs LLC, Peacekeepers Investments LLC Release of Liability/Assumption of Risk

Registration Agreement

Upon submission you will receive an email with additional forms that are required to be completed. Please complete these additional forms, print on white paper, and have them notarized. Additional instructions are included.