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BLACKFOOT POLICE DEPARTMENT CITIZENS ON PATROL APPLICATION NAME: ADDRESS: PHONE: DRIVER LICENSE: **Please attach photocopy of Driver License** EMPLOYMENT: Job EMERGENCY CONTACT: Submission of this application gives the Blackfoot Police Department your expressed consent to perform any background check the Blackfoot Police Department may deem necessary or appropriate. Any false statement, either verbal or written may be cause for applicant’s name to be removed from consideration or be cause for immediate dismissal from this program and return of all issued equipment. WAIVER: To the extent not covered by relevant City policies on defense of and payment against officials nd employees, I, do hereby agree to indemnify and hold harmless the Citizens On Patrol Program, Blackfoot Police department, and the City of Blackfoot, from any and all claims or causes of action that may arise out of performance of my patrol duties. I waive any right of action I have against the aforementioned entities’ in consideration of my participation as a volunteer for the Citizens On Patrol Program/Blackfoot Police Department. CONFIDENTIALITY STATEMENT: I realize that in my capacity as a volunteer for the Citizens On Patrol/Blackfoot Police Department I may come in contact with confidential information. I do agree to protect this information to the best of my abilities as a volunteer and not to divulge it during or after my service as a volunteer, except as legally necessary in the performance of those duties.