SAN DIEGO POLICE DEPARTMENT Page 1 of 2 Police Legal (PEF) 6/14 /2010 RIDE ALONG REQUEST FORM Date Received Home Phone Work Phone Name DOB Home Address STREET CITY/STATE ZIP Busin ess Address STREET CITY/STATE ZIP Occupation Driver’s Lic/ID SS# Division Assigned Shift Desir ed First Ride Along : Y / N Reason Request Received by AUTH ORIZATION FOR MEDICAL TREATMENT I understand and agree that the City of San Diego does not , and will not, provide medical coverage for me/my child, and I WILL BE RESPONSIBL E FOR ANY MEDICAL CO STS INCURRED as a result of participation in the activity. I give authorization to a physician or surgeon, licensed under the provisions of the Medical Practice Act, to give me /my child, ________________________________, care and/or emergency medical treatment when necessary. _____ ___________________ _______ _ ________________________ ______ _______ Participant or Parent (Print Name) Signature COORDINATOR USE Routed to _________________________ Date _______________ Watch ___________ Ride Along File Checked: Y / N Age Waiver: Y / N Captain Waiver: Y / N Records Check Results ____________________Warrant Check Results ___________________ SUPERVISOR USE Officer Assigned ____________________ If Ride Along Den ied, Why?____________________ OFFICER USE Officer Assigned __________________ Contact Date __________ Date of Ride Along _______ Obtain ID/Log Info. __________ Complete waiver _______ Advise Communications _______ Advise of Witness Obligation ___________ Advise of Safety Precautions ________ Officer’s Comments Attached: Y / N SAN DIEGO POLICE DEPARTMENT Page 2 of 2 Police Legal (PEF) 6/14 /2010 RIDE - ALONG WAIVER AND RELEASE O F LIABILITY For and in consideration of the permission granted to me, ____________________________________ (or to my child, ____________________________________), by the City of San Diego to accompany officers of the San Diego Police Department while on patrol, on ____________ (date), I agree that: 1. P articipation in the Ride - Along program is voluntary and I /m y child freely cho ose to participate; 2. I acknowledge that participation may include inherently dangerous activities. I understand that police patrol involves, on occasion, extraordinary circumstances which may be hazardous to person or property, and I assu me and acce pt all risks associated with par ticipation, including bodily injury or death, or other loss, including damage to property; 3. Understanding that participation in the activity could involve pote ntial risks of harm, not limited to those specified a bove, I DO RELEASE, HOLD H ARMLESS AND PROMISE NOT TO SUE THE CITY OF SAN DIEGO AND THE SAN DIEGO POLICE DEPARTMENT, ITS OFFICERS, EMPLOY EES, AGENTS, AND VOLUNTEERS, WITH RESPECT TO ANY AND ALL SUCH INJURY OR L OSS, except that injury or loss which results from the sole gross negligence or willful or wanton misconduct of one of those individuals; 4. I FURTHER AGREE TO I NDEMNIFY AND DEFEND THE CITY OF SAN DIEG O AND THE SAN DIEGO POLICE DEPARTMENT , its officers, employ ee s, agents, and volunteers , FROM AND AGAINST ANY AND ALL LIABILITY IN CURRED as a result of or in any manner related to participation in this activity . 5. I understand that while on patrol I/my child may become a material witness to incidents or events which form the basis for a criminal or civil proceeding. In this event, I/my child may be required by subpoena to testify as a witness. I AM AWARE THAT THIS CONTRACT IS LEGALLY BINDING AND THAT I AM RELEASING LEGAL RIGHTS BY SIGNING IT. I acknowledge by my signature that I have read and understand the terms that are set forth in this agreement. I have entered into this agreement freely and without duress. ________________________ ________ ________________________ ______ _______ Participan t or Parent (Print Name) Signature Date
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I give authorization to a physician or surgeon licensed under the provisions of the Medical Practice Act to give me my child care andor emergency medical treatment when necessary Participant or Parent Print Name Signature Date COORDINATOR USE ID: 4383 Download Pdf