Ride Along Liability Waiver by qfd13795

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Ride Along Liability Waiver document sample

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									                                              DEPARTMENT OF PUBLIC SAFETY
                                                        RIDE ALONG APPLICATION
                                                        AND WAIVER OF LIABILITY
The Department of Public Safety reserves the right to deny any application. False and/or misleading
information will result in denial of your request.

PLEASE PRINT
FIRST NAME                                          MIDDLE                                       LAST




      DATE OF BIRTH                                          DRIVER'S LICENSE #




HOME ADDRESS                                                 CITY                        STATE          ZIP




HOME TELEPHONE                                                        CELL PHONE




DAYS AND TIMES YOU WISH TO RIDE ALONG




OFFICER PREFERENCE




REASON YOU ARE REQUESTING A RIDE ALONG


HAVE YOU EVER BEEN CONVICTED OF A CRIME                                            Y               N
ARE THERE ANY CHARGES PENDING AGAINST YOU                                          Y               N


SIGNATURE                                                                          DATE

In consideration of my being permitted to ride in the motor vehicles of the GVSU Department of
Public Safety, I hereby release and agree to hold harmless the Department of Public Safety, Grand
Valley State University, its officers, employees, and agents, from any and all liability for any losses,
damages, expenses, personal injuries, psychological injuries, or death which might be suffered or
sustained by me directly or indirectly as a result of participation in an University Policing ride-along,
from any cause whatsoever. This release of liability and agreement given by me shall apply to any
right of action that might accrue to myself, my heirs, and my personal representatives. Further, I
am aware of the danger that may be involved in riding in a Police cruiser, and accompanying a
Police Officer in the course of performing his/her assigned duties.

SIGNATURE

(To be signed in the presence of Police Department personnel)                      DATE


                                               ***POLICE USE ONLY***
CCH reviewed by:                                                      Approved/Denied by:

Scheduled Date/Time:                                                  Officer Assigned

Observer DID / DID NOT participate in a ride along on the above indicated time

								
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