| PART A. PERSONAL INFORMATION |
| * Full Name | |
| * Date of Birth | |
| * Address | |
| * City | |
| * State | |
| * Zip | |
| * Cell Phone | |
| Other Phone | |
| * Driver's License | |
| * Email Address | |
| *Emergency Contact Name: | |
| *Emergency Contact Phone: | |
| PART B. APPLICATION QUESTIONS |
| * Why do you want to participate in the Ride Along program? | |
| * Have you participated in the Ride Along program in the past? | Yes No |
| If yes, when? | |
| If yes, please provide a brief explanation. (A criminal history check will be conducted prior to your scheduled Ride Along) | |
| * Do you have a history of any of the following medical conditions? | High Blood Pressure Yes No Heart Condition Yes No Nervous or Mental Condition Yes No |
| If you answered YES to any of the above, please provide a brief explanation. | |
| * Please select the shifts that you are available to ride along. | Day: 0630-1030 Relief: 1200-1600 Swing: 1600-2000 Graveyard: 2130-0130 |
| * Please indicate if you have a preferred shift and date(s) that you would like to ride along | Date(s) Shift |
| PART C. APPLICATION ATTESTATION (please initial) |
| * All ride alongs shall be dressed in casual business attire (Jeans are not permitted) | |
| * Applicants must be 15 1/2 years of age or older at the time of application | |
| * Applicants are not allowed to ride more than once in any 12 month period | |
| * Applicants must be able to promptly follow the spoken instructions of the Host Officer, enter/exit the patrol car unassisted, and take evasive action in an emergency. | |
| * Have you ever been arrested? | Yes No |
| All applicants must be residents of the City of Roseville, or select ONE of the qualifying options that apply | |
| If you are a Non-Resident of Roseville with a valid City of Roseville business license, please enter your business address. | |
| If you are a criminal justice student, please enter the name of your institution | |
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PARTICIPANTS ARE PROHIBITED FROM RECORDING THEIR RIDE ALONG BY VIDEO, AUDIO OR STILL PHOTOGRAPHY WITHOUT PRIOR WATCH COMMANDER APPROVAL |
PART D. WAIVER AND RELEASE OF LIABILITY (please initial and sign) |
| * WHEREAS THE UNDERSIGNED HAS REQUESTED PERMISSION TO RIDE AS A GUEST/OBSERVER IN A CITY OF ROSEVILLE POLICE DEPARTMENT VEHICLE AND TO ACCOMPANY AN EMPLOYEE(S) OF THE CITY OF ROSEVILLE POLICE DEPARTMENT DURING THE ACTIVE PERFORMANCE OF THEIR OFFICIAL DUTIES AS POLICE OFFICERS; | |
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| * AND THE UNDERSIGNED ACKNOWLEDGES THAT THE WORK AND ACTIVITIES OF THE CITY OF ROSEVILLE POLICE DEPARTMENT IN CONNECTION WITH THE RIDE ALONG ARE INHERENTLY DANGEROUS, INVOLVING POSSIBLE RISK OF PERSONAL INJURY, DEATH, DAMAGE, EXPENSE, OR LOSS TO PERSON OR PROPERTY; | |
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| * AND THE UNDERSIGNED HEREBY AGREES TO HOLD HARMLESS AND RELEASE THE CITY OF ROSEVILLE, INCLUDING THE ROSEVILLE POLICE DEPARTMENT, ANY EMPLOYEE OR VOLUNTEER OF THE CITY OF ROSEVILLE, THE DRIVER OR OWNER OF ANY AUTOMOBILE OWNED OR OPERATED BY OR IN THE SERVICE OF THE CITY OF ROSEVILLE, THEIR SURETIES, INSURERS, AND EACH OF THEM, FROM LIABILITY OR RESPONSIBILITY UNDER ANY CIRCUMSTANCES WHATSOEVER BY THE UNDERSIGNED, HIS OR HER ESTATE OR HEIRS, FOR ANY INJURY, DEATH, DAMAGE, EXPENSE OR LOSS OF ANY KIND TO THE PERSON OR PROPERTY OF THE UNDERSIGNED, INCURRED WHILE RIDING IN ANY CITY OF ROSEVILLE VEHICLE, OR WHILE ACCOMPANYING AN EMPLOYEE OF THE CITY OF ROSEVILLE DURING THE ACTIVE PERFORMANCE OF HIS OR HER OFFICIAL DUTIES AS A PEACE OFFICER. | |
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| I, THE UNDERSIGNED APPLICANT DECLARE UNDER PENALTY OF PERJURY THAT I HAVE GIVEN CORRECT INFORMATION IN THE FOREGOING APPLICATION AND THAT I HAVE READ AND UNDERSTAND THE ABOVE AGREEMENT ASSUMING RISK OF INJURY OR DAMAGE, WAIVER AND RELEASE OF CLAIMS; AND THAT I KNOWINGLY AND WILLINGLY ASSUME THE RISK OF ANY LOSS, DEATH, DAMAGE, OR INJURY OF ANY KIND WHATSOEVER, WHICH I MAY INCUR AS A RESULT OF PARTICIPATING IN THE CITY OF ROSEVILLE POLICE DEPARTMENT "RIDE ALONG" PROGRAM. |
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| * APPLICANT SIGNATURE / DATE | |
| PARENT/GUARDIAN SIGNATURE (IF UNDER 18 YEARS) | |