INSTRUCTIONS TO APPLICANT
Approved applicants shall meet the following requirements and assume responsibilities as stated: 1. Citizen or representative of civic group, or applicant for position of Police, Prince William County or other County employees authorized by the District Commander. Resident of District Station this is receiving application. Eighteen years of age or older. No participation in program within the past twelve months unless an applicant for Police Officer with Prince William County Police Department. Participants are required to present a neat, clean appearance (no jeans). Follow all instructions by officer during program; no interference with the performance of the officer shall be permitted. The ride-along program shall be conducted at times which are convenient to the operations of the District Station. The duration of the ride is at the discretion of the on-duty supervisor. No cameras or tape recorders are permitted to be used by the citizens while riding due to the possible conflicts with evidence collection. Participants are not to leave the patrol car at the scene of police activity without obtaining permissions of the officers. Participants shall report to the District Station on the date advised, fifteen minutes prior to the schedule time of the program.
2. 3. 4.
5. 6. 7. 8. 9. 10. 11.
PD29 Rev. 01/22/04
PRINCE WILLIAM COUNTY POLICE APPLICATION FOR RIDE-ALONG PROGRAM
The Ride-Along Program is designed to allow citizens a “behind the scenes” look at the Prince William County Police Department in action. It is our hope that the insight into the line operations of the Department will be both informative and enjoyable. The following information is requested to participate in the program:
Name: First SSN: Address: Street Phone #s: Home: City Work/Cell: State Zip Code Middle DOB: Last Race:
Occupation: Emergency Contact/Phone #: Date Desired:* Shift Desired:** Are you currently an applicant of the Prince William County Police Department? Yes No Do you have any medical condition that might affect you ability to participate in the program? Yes No If yes, please explain: Have you ever been arrested? Yes If yes, please explain: No
Describe your reason for wanting to participate in this program:
*Please list an alternate date. **Shift Choices are: 7A – 5P; 4P – 2A; 9P – 7A
PD29 Rev. 01/22/04
RIDE-ALONG PROGRAM ADULT RELEASE
WHEREAS, I, ____________________________________, have requested that the Prince William County Police Department (hereinafter the “Police Department”), for my own personal benefit, grant me permission to participate in the Prince William County Police Ride-Along Program by riding in a police cruiser and by otherwise observing and accompanying police officers during a tour of duty, and the said Police Department has indicated that it is willing to grant my request providing that I execute in writing this instrument releasing the said Police Department and the Government of Prince William County, and its or their officers, agents, or employees from and against any and all suits or claims for losses, damages, expenses, personal injuries, or death which might be suffered or sustained by me directly or indirectly as a result of participation n the Ride-Along Program. NOW, THEREFORE, BE IT KNOWN THAT I, the undersigned, am over 18 years of age and for and in consideration of the permission granted by the Police Department to me to observe police during a tour of duty, and to ride in a police motor vehicle and otherwise accompany police officers for said purpose do hereby, while in a police vehicle, in any building, or on any property or premises owned or operated by the Police Department or the County of Prince William, or while otherwise participating in the Ride-Along Program, and do discharge the said Police employees from and against any and all claims, under or through me have, or can or might have, as a result of any loses, damages, expenses, personal injuries or death which I or any persons whosoever claiming under or through me, may suffer or sustain while exercising said permission, in any motor vehicle, in any building, or on any property or premises owned or operated by the Police Department or County of Prince William, or while otherwise participating in the Ride-Along Program, whether said losses, damages, personal injuries or death result from the negligence of the said Police Department or the County of Prince William, its officers, agents, or employees, or are otherwise caused. __________________________________________________ Applicant Signature Date: _____________________________________________ COMMONWEALTH OF VIRGINIA: COUNTY OF PRINCE WILLIAM:
The foregoing instrument was acknowledged before me this _________ day of ____________________ 20______.
________________________________________ Magistrate Notary Public If Notary: My term of office expires on the _______ day of _____________20____
PD29 Rev. 01/22/04
PRINCE WILLIAM COUNTY POLICE DISTRICT STATIONS
Gar-Field Station at 15948 Donald Curtis Drive, Woodbridge, Virginia 22191 Manassas Station at 8900 Freedom Center Blvd., Manassas, Virginia 20110 I certify that I understand the requirements and responsibilities of participants in this program and that I am aware of the potential risk involved with accompanying a police officer during the performance of his/her duties. Signature: ___________________________________ Date: ____________________ Application received by: _________________________________________________ Applicant interviewed by: __________________________________________________ Applicant approved by: _________________________________________________ Approved with the following additional conditions: ___________________________ FOR DEPARTMENT USEONLY
Local Record Status: CCH Check:
Negative Negative
Positive Positive
Initials: ___________ Initials: ___________
Checks revealed the following: _____________________________________________ _________________________________________________________________ Application approved by: _________________________________ Date: __________ Name TO BE FILLED OUT BY ROAD SUPERVISOR AT THE TIME OF THE RIDE ALONG Assigned to: ______________________(Officer Name) Date Citizen Rode: _____________________________ Shift: ____________________ Road Supervisor’s Signature: _______________________________________________ Comments:
PD29 Rev. 01/22/04