Ride-Along Program Request for Consideration "*" indicates required fields Δ Personal InformationYour Name* First Last Date of Birth MM slash DD slash YYYY PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address* Emergency Contact InformationEmergency Contact Name First Last Emergency Contact PhonePREREQUISITES The Vanderburgh County Sheriff’s Office Civilian Ride-Along Program was designed in an effort to show an understanding of how a law enforcement agency functions. It is an important tool to affect good relations between the community and its law enforcement agency. The following are required prior to participating: Must be eighteen (18) years of age or older to participate with no felony arrests Complete this form ten (10) days prior to the desired date of participation Available Shifts The Vanderburgh County Sheriff’s Office Civilian Ride-Along Program is limited to one eight (8) hour Ride-Along Session each calendar year. 1st Shift 0600-1400 hrs. (6:00 a.m. to 2:00 p.m.) 2nd Shift 1400-2200 hrs. (2:00 p.m. to 10:00 p.m.) 3rd Shift 2200-0600 hrs. (10:00 p.m. to 6:00 a.m.) Please list two dates and times that you would love to participate in this program. An Operations Supervisor will contact you to advise of the date and time for the Ride-Along. 1st Choice MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM 2nd Choice MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM WAIVER AND RELEASE AGREEMENT AND INFORMED CONSENT FOR VANDERBURGH COUNTY/VANDERBURGH COUNTY SHERIFF’S OFFICE CIVILIAN RIDE-ALONG PROGRAMPROGRAM Participant Consent* I agree to the following statements:The undersigned, being at least eighteen (18) years of age, and in consideration for acceptance, approval, and participation in the Civilian Ride-Along Program (the “PROGRAM”), sponsored by Vanderburgh County (the “County”) and the Vanderburgh County Sheriff’s Office (the “Sheriff’s Office”), does hereby agree to this waiver and release agreement (the “Agreement”). I recognize that the PROGRAM will involve physical activity and may carry a risk of personal injury, and may cause me physical or emotional discomfort. I further recognize that there are natural and man-made hazards, environmental conditions, diseases, and other risks, which in combination with my actions in the PROGRAM, can cause injury to me. I hereby agree to assume all risks which may be associated with or which may result from my participation in the PROGRAM. I state that I am free from any known health conditions that could prevent me from participating in any of the activities associated with the PROGRAM. I further state that I am sufficiently physically fit to participate in the activities of this program. I certify that at all times, I shall have medical insurance to cover the cost of any medical care, emergency or otherwise, that I may receive for any illness or injury created by my participation in the PROGRAM. In the event I fail to have medical insurance, I certify that I will be personally responsible for the cost of any medical care, emergency or otherwise, that I receive. I further agree to release, indemnify and hold harmless the County and the Sheriff’s Office, their agencies, departments, officers, employees, agents, representatives, affiliates, directors, servants, volunteers, members, sponsors, and/or officials, and staff from any such entity or person, their representatives, agents, affiliates, directors, servants, volunteers, and employees from the costs of any medical care that I receive while participating in the PROGRAM or as a result of it. I further agree to release, indemnify, and hold harmless the County and the Sheriff’s Office, their agencies, departments, officers, employees, agents, representatives, affiliates, directors, servants, volunteers, members, sponsors, and/or officials, and staff of any such entity or person, their representatives, agents, affiliates, directors, servants, volunteers, and employees from any and all liability, claims, demands, actions, and causes of actions whatsoever for any loss, claim, damage, injury, illness, attorneys fees or harm of any kind or nature to me arising out of any and all activities associated with my participation in the PROGRAM. I further agree to release, indemnify, defend, and hold harmless the above-mentioned entities and representative officials from all liability, negligence, or breach of warranty associated with injuries or damages from any claim by me, my family, estate, heirs or assigns from or in any way connected with my activities in the PROGRAM. I further agree to indemnify, defend and hold harmless, and do hereby release the above-mentioned entities and representative persons from all liability, negligence or breach of warranty associated with injuries or damages caused by my participation in the PROGRAM to any third party(ies). I HAVE CAREFULLY READ AND UNDERSTAND THE CONTENTS OF THE AGREEMENT AND STATE THAT THE CONTENTS OF THIS AGREEMENT HAVE BEEN FULLY EXPLAINED TO ME. I DO HEREBY CERTIFY, STATE AND ACKNOWLEDGE THAT I AM NOT UNDER THE INFLUENCE OF ALCOHOL OR ANY MIND-ALTERNATING SUBSTANCE WHATSOEVER, FREE OF ANY DURESS OR COERCION AND VOLUNTARILY, KNOWINGLY AND WILLINGLY EXECUTE THE AGREEMENT INTENDING IT TO COVER MY PARTICIPATION IN THE PROGRAM SPONSORED BY THE CITY AND DEPARTMENT. Today's Date MM slash DD slash YYYY INFORMED CONSENT FOR MEDICAL TREATMENTConsent if expressly given, in the event of injury, for any emergency medical treatment, including, but not limited to, anesthesia and/or operation, if, in the opinion of the attending physician, such treatment is necessary.Digital Signature By checking this box, I consent to sign electronically.A clicked box serves as a digital signature for the following person.Participant Name First Last Today's Date MM slash DD slash YYYY CAPTCHA