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* NAME

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* PHONE

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* EMAIL

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* ADDRESS

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* DATE OF BIRTH

Date

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* SEX

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* RACE

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* OCCUPATION

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* DRIVER'S LICENSE #

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* SOCIAL SECURITY #

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* ARE YOU APPLYING TO RIDE AS PART OF A CRIMINAL JUSTICE COURSE?

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* IF YES, WHAT IS THE NAME OF YOUR SCHOOL?

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* ARE YOU INTERESTED IN A CAREER IN LAW ENFORCEMENT?

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* BRIEFLY STATE YOUR REASONS FOR PARTICIPATION IN THE RIDE ALONG PROGRAM

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* PLEASE INDICATE YOUR PREFERRED DAY OF THE WEEK

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* PREFERRED DATE OF RIDE ALONG, IF APPLICABLE

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* CHOOSE YOUR PREFERRED TIME FROM THE FOLLOWING OPTIONS

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* NAME OF REQUESTED OFFICER, IF APPLICABLE

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* PERMIT, RELEASE, INDEMNIFICATION AGREEMENT AND AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION
In consideration of being granted to ride in the City of Springfield police vehicle and of accompanying a City of Springfield police officer for the purpose of observing and becoming familiar with the operations of a City of Springfield police officer in the actual performance of his duties, do hereby release and discharge the City of Springfield, and the Springfield Police Department and all of their officers and employees from all liability to me, my employer, my assigns, my heirs, my executors and personal representatives, now and forever, for all loss or damage, in any claim or demands therefore on account of injury or casualty to myself or my property, whether by negligence or otherwise, during such time that I am participating in the Citizen Ride Along Program, for the above mentioned purposes, while said officer is officially discharging his duties. I further assume all risk of death, injury, loss or damage to my person or property, whether due to negligence or otherwise, and neither myself nor any of my representatives shall have any right or claim against the City of Springfield Police Department, their officers or employees, in respect or arising out of any such death, injury, loss or damage. I further hereby agree to indemnify and save harmless the City of Springfield Police Department and all of their officers and employees on account of any debt, expense, claim, obligation or any sum of money which they may be required to pay on account of any liability or damage by reason of injury to me or damage to my property, whether by negligence or otherwise, while I am participating in the Citizen Ride Along Program. I further hereby authorize a review of and full disclosure of all records concerning myself to a duly authorized agent of the Springfield Police Department, whether the said records are of a public, private or confidential nature. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of the release or collection of such information. I also understand this authorization to furnish information is executed in consideration of the processing of my application for participation in the Springfield Police Department “Citizen Ride-Along Program.” I have read and fully understand the contents of this “Citizen Ride-Along Program Permit Release, Indemnification Agreement and Authorization for Release of Personal Information".

* ELECTRONIC SIGNATURE

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* DATE

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* PLEASE UPLOAD A PHOTO OF YOUR DRIVER'S LICENSE

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* FOR OFFICE USE ONLY: RECORD / NO RECORD

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* FOR OFFICE USE ONLY: DATE/TIME OF RECORD CHECK

Date
Time

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