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W WOODBURN POLICE DEPARTMENT 1060 Mt. Hood Avenue, Woodburn, Oregon 97071 Phone: (503) 982-2345 FAX: (503) 982-2370 CITIZEN OBSERVER (RIDE-ALONG) PROGRAM APPLICATION LAST NAME FIRST NAME MIDDLE NAME MAIDEN STREET/MAILING ADDRESS CITY ZIP CODE HOME/CELL PHONE DATE OF BIRTH WORK PHONE SOCIAL SECURITY NUMBER I hereby request permission to ride as a civilian observer in a Police Department patrol vehicle because . I further agree with and voluntarily sign the Release and Hold Harmless Agreement (on reverse). All requested dates listed below are at least ten (10) days after submitting this application: 1st Choice: Date Time 2nd Choice: Date Time 3rd Choice: Date Time Signature of Applicant Date - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - (FOR OFFICE USE ONLY) Date/Time Received By Checks: CCH Wanted DL Approved/Denied Notified By Date Assigned Date/Time/Officer Host Officer Name/Comments ---PAGE BREAK--- POLICE DEPARTMENT CITIZEN OBSERVER (RIDE-ALONG) PROGRAM RELEASE AND HOLD HARMLESS AGREEMENT In consideration of being permitted to ride in a vehicle owned and operated by the City, for the expressed purpose of observing operations and facilities of the Police Department, the undersigned agrees to release and hold harmless the City, its agents, employees, and elected official from any and all liability to me for personal injury or death or any property damage, whether proximate or remote, sustained during or as a result of my ride as an observer. I understand that I will be a guest passenger in the vehicle in which I ride and have not offered any payment to the Police Department or its employees for the opportunity to ride. I further understand that I may be summoned as a witness in any proceeding as a result of my observations. This observation is for my educational benefit. At all time, I agree to obey all orders, instructions and commands of the officer(s) of the Police Department. I fully realize and appreciate the basic nature of law enforcement and the possibility that situations may arise which might result in my exposure to danger of physical harm or injury, including traffic accidents, and I am willing to accept these risks. I further agree to keep confidential anything which I may observe or hear. I understand that my observation ride may be terminated at any time without notice. I authorize the Police Department to conduct a complete records check of me prior to riding and understand that any information of an adverse or criminal nature may disqualify me. I freely and voluntarily sign this Release and Hold Harmless Agreement in sole reliance of my own independent judgment. Signature of Applicant Date PARENTAL ENDORSEMENT (For applicants under age of 18): I have read and understand the Release and Hold Harmless Agreement and agree to be bound to its provisions as they apply to my son/daughter . I agree to assume full responsibility for my son/daughter as it would pertain to the provisions set forth. Parent/Guardian Signature Date