SPD Ride Along Application Question Title * NAME Question Title * PHONE Question Title * EMAIL Question Title * ADDRESS Address City/Town ZIP/Postal Code Question Title * DATE OF BIRTH PLEASE ENTER Date Question Title * SEX MALE FEMALE Question Title * RACE White Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race Question Title * OCCUPATION Question Title * DRIVER'S LICENSE # Question Title * SOCIAL SECURITY # Question Title * ARE YOU APPLYING TO RIDE AS PART OF A CRIMINAL JUSTICE COURSE? Yes No Question Title * IF YES, WHAT IS THE NAME OF YOUR SCHOOL? Question Title * ARE YOU INTERESTED IN A CAREER IN LAW ENFORCEMENT? Yes No Question Title * BRIEFLY STATE YOUR REASONS FOR PARTICIPATION IN THE RIDE ALONG PROGRAM Question Title * PLEASE INDICATE YOUR PREFERRED DAY OF THE WEEK SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY Question Title * PREFERRED DATE OF RIDE ALONG, IF APPLICABLE Question Title * CHOOSE YOUR PREFERRED TIME FROM THE FOLLOWING OPTIONS 8A-12P 7P-11P 11P-3A Question Title * NAME OF REQUESTED OFFICER, IF APPLICABLE Question Title * 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 Question Title * DATE Question Title * PLEASE UPLOAD A PHOTO OF YOUR DRIVER'S LICENSE PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File PLEASE UPLOAD A PHOTO OF YOUR DRIVER'S LICENSE Done