Form Center

By signing in or creating an account, some fields will auto-populate with your information.
The following form may request personally identifiable or protected health information. Please see our Privacy Policy for details. This form is encrypted. SSL is on to ensure a higher level of security. A recaptcha must be completed before submission, you cannot save progress, and you cannot receive an email copy of the form.

Ride-Along-Program Waiver

Steps

  1. 1. Waiver
  2. 2. RELEASE OF PERSONAL CRIMINAL HISTORY
  • Waiver

    1. Hereinafter "Rider"

    2. (Include City, State, Zip)

    3. I, a resident of the above address, am interested in observing the operations of the Carbondale Police Department in accordance with the Ride-Along Program. I understand that to observe such operations, it may be necessary for me to ride in patrol cars, observe the operation from within the Department, and participate in other police activities. I further understand that I may be placed in some potentially dangerous situations to me physically or to my property. I understand that some of these situations may be emotionally distressful or traumatic. I understand that the Carbondale Police Department will conduct a criminal history background check on me prior to allowing me to participate in the Ride-Along Program. I hereby agree to follow all of the policies and procedures of the Carbondale Police Department. I further agree that I shall follow the directions of the Carbondale Police at all times while I am engaged in ride-along activities. I understand that if I fail to follow these directions, the ride-along will be terminated and I will be prohibited from participating in the Ride-Along Program with the Carbondale Police Department. I hereby waive, release, discharge, and/or hold harmless the City of Carbondale, the Carbondale Police Department, and all of their agents, officers, officials, employees, and assigns from all manner of actions, causes of action, suits, debts, and sums of money, dues, claims and demands, in law or equity arising out of said ride-along, including but not limited to claims for physical injuries to me, damages to my property, or claims for emotional distress or trauma. I understand and agree that I shall be solely responsible for any and all damages arising out of my participation in said Ride-Along Program.

    4. (Must be at least 15)

    5. Do you have a preference for a particular shift or officer?*
    6. Electronic Signature Agreement*

      By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.