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Public Safety Ride-Along Form and Hold Harmless Agreement

2. Release, Covenant Not to Sue, and Hold Harmless Agreement
4. Parties: City of Grants Pass, hereinafter referred to as City, and (name) hereinafter referred to as Rider/Observer.
6. Name
   enter your full name
8. Rider/Observer Information
10. Select One:*

    1. Police

    1. Fire
12. First Name*
13. Middle Initial*
14. Last Name*
15. Date of Birth*
17. Address*
18. Telephone*
20. Employer/School*
21. Telephone*
23. Identification*
    Enter Driver's License. Do not enter Social Security Number. If that is your identification, enter "SSN" in field, and print it on the form when you print it out to sign.
25. Emergency Information
    The following information is requested for emergency purposes only.
27. Medical Information
    List any medical problems for which rider is being treated or past medical problems of which the City should be aware.
29. Emergency Contacts
    List two people who can be notified in case of an emergency.
31. Name
32. Telephone
34. Name
35. Telephone
37. Family Physician
38. Telephone
40. Participation Request
42. I am requesting this opportunity to participate in the observation of the Grants Pass Department of Public Safety for the following reason:
44. Check any that apply at the time of this request. (Academy)

    1. Currently enrolled in Citizens Public Safety Academy
    2. Currently enrolled in Student Academy
    3. Prior Citizen Public Safety Academy or Student Academy Attendee
45. If prior attendee, what dates did you attend the Academy?
47. Current applicant for a position with the Grants Pass Department of Public Safety?

    1. Yes
    2. No
48. Which Position did you Apply for, and what was the date of the application.
50. Attended presentation by the GPDPS that prompted me to request this observation period.

    1. yes
    2. no
51. If so, what was the presentation, the date held, and who presented?
53. Family member of GPDPS

    1. yes
    2. no
54. If so, which employee?
56. Prior Approval of a GPDPS Supervisor?

    1. yes
    2. no
57. If so, which Supervisor?
59. Recitals

61. WHEREAS:

    A. The City is willing to allow the Rider/Observer the opportunity to accompany and ride with a police officer(s) in a police vehicle or fire fighter(s) in a fire vehicle, while in the performance of their duties, for the purpose of observation, said opportunity hereinafter referred to as “ride along.”
    
    

    B. The City is willing to allow the Observer the opportunity to sit-in the Dispatch or Records Section to observe dispatchers/records personnel in the performance of their duties, for the purpose of observation, hereinafter referred to as “sit-in”.
    
    

    C. The Rider understands and appreciates that there are known and unknown risks which the Rider will be exposed to in a ride along, and Rider does not wish to hold the City of Grants Pass, or any of its officers, employees, agents, or representatives responsible in either a Municipal or personal capacity for any injury, death, disability, or damages to property that may occur as a result of the ride along, regardless of who may be at fault. Rider knows that the risks are too numerous to mention herein, but include without limitation, such things as traffic accidents, the discharge of firearms, fights, brawls, altercations, riots, fire calls, rescue calls, medical calls, hazardous material calls.
    
    

    D. The observer understands that while observing they will see and hear information that is confidential in nature, including information on a computer terminal. Disclosure of any information can result in criminal and civil charges being filed against the observer and can result in civil liability for the public safety agency involved. Therefore, in order to protect the confidentiality of the information and to protect the integrity of agreements which the Grants Pass Department of Public Safety has with local, state, and federal agencies the observer agrees that any and all information that they see, hear or discuss while participating in the observation period will not be repeated to anyone without written permission of the Grants Pass Department of Public Safety Director.

    
    

    NOW, THEREFORE, in consideration of the above and of the mutual covenants contained herein:

    1. PERMISSION:  The City agrees to let rider/observer participate in a “ride along” or “sit-in”
    2. PARENT OR LEGAL GUARDIAN: If rider/observer is under 18 years of age, Rider/observer’s Parent or Legal Guardian must also sign and agree to the terms of this RELEASE, COVENANT NOT TO SUE AND HOLD HARMLESS AGREEMENT.  The parent or Legal Guardian agrees that all provisions referring to rider/observer are to be interpreted as rider/observer and rider/observer’s Parent or Legal Guardian.
    3. BINDING: Rider/observer is signing this document with the express intention of binding Rider/observers, Rider/observer’s heirs, personal representatives and assigns.
    4. INTERPRETATION: This RELEASE, COVENANT NOT TO SUE, AND HOLD HARMLESS AGREEMENT is to be interpreted in the broadest sense possible in favor of the City of Grants Pass, its officers, employees, agents and representatives shall include but not be limited to death, disability, injury, and property damage.
    5. VOLUNTARY AND TRUTHFUL: Rider/observer is signing this RELEASE, COVENANT NOT TO SUE, AND HOLD HARMLESS AGREEMENT as a voluntary act and deed and acknowledges that the representatives made herein by Rider/observer are true.
    6. RELEASE AND INDEMNIFICATION: Rider/observer does hereby agree to indemnify, release, save, protect, hold harmless, discharge, and covenant  not to sue nor to institute any action of law or in equity against, the City of Grants Pass, Oregon, and all of its officers, employees, agents, and representatives, for and from any and all claims, demands, actions, liabilities, judgments, and executions that Rider/observer (or anyone claiming through or under Rider/observer) ever had, now has, or may have in the future, known or unknown, which might or do arise from, are created by, or are a consequence of Rider/observer’s participation in the ride along or sit-in,  including, but not limited to; the arrival, preparation, and departure related to the ride along, whether in a City or personal vehicle, death, disability, injury, and property damage.
    7. DEFENSE: This RELEASE, COVENANT NOT TO SUE, AND HOLD HARMLESS AGREEMENT may be plead by the City of Grants Pass, and any officer, employee, agent and representative of the City of Grants Pass, as a complete defense to any claim, demand, action, judgment, execution, or proceeding that may be brought or instituted by Rider/observer or by Rider/observer’s Parents, Guardians, heirs, personal representatives, legal representatives and assigns.
    8. READ AND UNDERSTOOD: Rider/observer’s represents and confirms that Rider/observer has carefully read, and understood this document and also understand that Rider/observer is free to, and should, contact a private attorney if Rider/observer has any questions concerning anything in this document or the advisability of signing this document.
63. Signature Instructions
    1. Submit and Print the application
    2. Fill out the signatures and dates by hand
    3. If you use your social security number as your identification, fill in the Identification field by hand.
    4. Bring the printed and signed application to the Department of Public Safety
65. Notice to Rider (Guardian if Rider Under 18 Years of Age)
    For safety reasons, the passenger side air bags on patrol cars equipped with Mobile Data Terminals (MDT) have been disabled. As a result, in the event of a front end collision, there will be no air bag deployment on the passenger side of the vehicle.
67. (signature of rider/observer)
68. Date
    Date

    Date
70. (signature of rider/observer)
71. Date
    Date

    Date
73. Witness Signature
    Witness to signature of Rider/Observer, and witness to signature of parent or guardian if Rider/Observer is under 18 years of age:
75. Name (please print)
77. Address
    Enter your full address
79. Telephone
81. Signature of Witness
82. Date
    Date

    Date
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit Submit and Print

* indicates a required field