8/7/2019 Ranger Academy Application 2011

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Name (Last, First, Middle):

Street / Route / Box:

City, State, ZIP Code:

Phone Number(s): Home:

E-Mail Address:

Date of Birth: Place of Birth - City, County, State:

Male Female U.S. Citizen? Yes No

Education: Highest Level Attained:

High School Graduated From or GED Awarded at (Date, Name, City, State):

Race: Caucasian Native American

Hispanic Other

Ranger Academy Dates Desired:

August to December Year: Year:

Method Of Payment: Cash Check Charge

Credit Card Owner: Expiration Date:

Please Make Checks Payable to Hocking College

Mail To: The National Ranger Training Institute at Hocking College

Attention: Connie Cassady

3301 Hocking Parkway

Nelsonville, Ohio 45764

Questions? Please Contact Connie Cassady at 740-753-6304 or Bill DeWeese at740-753-6295

African American

Asian / Pacific Islander

Select Summer/Fall Academy or Winter/Spring Academy and Year You Wish to Attend

January to May

(Note that charges requires the

addition of a $5.00 fee)

MasterCard Visa Discover Number

3 Digit CVN Number

Ranger Academy Program

Preliminary Application

Please Return This Form With Your $125 / $130 Deposit

(Deposit Will Reserve Your Space in the Class and is Refundable)

Other:

Social Security Number Driver's License: State, Number, Expiration Date

8/7/2019 Ranger Academy Application 2011

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The Ranger Academy Program is physically challenging and requires that students reach a certain level of fitness before they are certified to graduate. Please list any medical, physical or other conditions that mayimpact your ability to perform exercise and strenuous physical activities. Also list any surgeries you havehad, and any chronic medical conditions that require ongoing medication or treatment, such as asthma orarthritis. If you have none, please list “None” or Not Applicable,”

Various Federal and State laws prohibit persons convicted of certain crimes from the possession or use of firearms or participation in law enforcement training. Please list any arrests or criminal complaints you havebeen subject to, their dates and outcomes. Also list any serious traffic citations you have received foroffenses that could or did result in a suspension of your operator’s license and or criminal charges. This

includes, but is not limited to, reckless operation, operating a vehicle under the influence of drugs oralcohol, or accidents that resulted in injury. For these purposes “vehicle” includes any motor vehicle, off-highway vehicle, watercraft, aircraft, construction or agricultural equipment, or non-motorized means of transportation operated on a public roadway, such as a bicycle or animal-drawn conveyance. If you havenone, please list “None” or Not Applicable,”