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2. NAME*

   (FIRST, MIDDLE, LAST)

4. Street Number*
5. Street Name*
6. Street Type*
7. Apt #
9. City*
10. State*
11. Zip*
13. Phone Number*
15. PLACE OF EMPLOYMENT*
16. ADDRESS OF EMPLOYMENT*
18. WORK PHONE NUMBER*
20. AGE*
21. DATE OF BIRTH*

    (MM, DD, YYYY)

23. RACE*
24. SS#*
26. LIST ANY HEALTH PROBLEMS HERE
28. REQUESTED DATE OF RIDE*

    (MM, DD, YYYY)

29. STARTING TIME*
31. REQUESTED DEPUTY (IF ANY)
33. EMERGENCY CONTACT INFO
35. NAME*
36. RELATIONSHIP*
38. Phone Number*
40. Street Number*
41. Street Name*
42. Street Type*
43. Apt #
45. City*
46. State*
47. Zip*
49. CLEAR CREEK COUNTY SHERIFF’S OFFICE RELEASE AND INDEMNIFICATION AGREEMENT

51. I, in and for the consideration of the Clear Creek County Sheriff’s Office permitting me to ride or participate as an observer in a Police vehicle, in the Sheriff’s Office or Sheriff’s Detention Facility.  I understand during a ride-along, while such vehicle is used for on-duty police functions, or during a Shift Observation I do hereby release and forever discharge and covenant to hold harmless, for myself and my heirs, personal representatives, administrators, successors and assignees, the Clear Creek County Sheriff’s Office and any of their officers, agents or employees, any and all other officers, agents or employees, and any and all other persons, firms, and corporation of and from any and all liability for any and all claims, demands, damages, costs, liabilities, losses and causes of action, which may arise incidental to my accompanying such County employees or agents in such vehicle on any occasion on which I ride as an observer or in such facility while I participate as an observer.. 

    I further understand that police activities, by their very nature, can and will in all probability, involve some danger. I hereby fully assume the risk for any of the potential dangers which are associated with police patrol and detention activities as a condition to being granted this privilege. 

    I further agree to fully indemnify the County of Clear Creek and the Clear Creek County Sheriff’s Office and any and all of their officers, agents or employees from any and all third party claims, demands, or causes of action for damages, costs, liability and losses of any kind which result from an injury due to acts or omissions on my part at any time upon which I am a participant in the Clear Creek County Ride-Along or Shift Observation Program. 

    I understand that the privilege and authorization which is granted to me by the approval of this Release and Indemnification Agreement may be revoked at any moment, if in the opinion of the supervising officer or any Sheriff’s Office member, my actions constitute a hazard or hindrance to any aspect of police duties or safety. 

    I further warrant that no promise or inducement has been offered except as herein set fo1th that this Release and Indemnification Agreement is executed without reliance upon any statement or representation by the persons or parties released, or their representatives, concerning the nature or extent of any potential damages or legal liability, therefore.

53. I warrant that I am legally competent to execute this document. (This paragraph applies only to those 18 years of age or older). On this date of:*
    I warrant that I am legally competent to execute this document. (This paragraph applies only to those 18 years of age or older). On this date of:

    I warrant that I am legally competent to execute this document. (This paragraph applies only to those 18 years of age or older). On this date of:
54. State of Colorado County of:*
56. Sworn to and subscribed before me this date of:*
    Sworn to and subscribed before me this date of:

    Sworn to and subscribed before me this date of:
58. PARENTAL PERMISSION AND AGREEMENT

    (Necessary for All Persons Under 18 Years of Age) 

60. I,
61. am the parent or legal guardian of,
63. has my permission to ride as an observer in a Clear Creek County Sheriff’s vehicle as provided above. It is hereby agreed that I am a party to this Release and Indemnification Agreement and that said agreement is binding upon me, said child, and any and all our legal heirs and successors of whatever kind. I further warrant that I am legally competent to execute this document.
65. Dated this day:
    Dated this day:

    Dated this day:
66. State of Colorado County of:
68. Sworn to and subscribed before me this day:
    Sworn to and subscribed before me this day:

    Sworn to and subscribed before me this day:
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70. 1. Receive an email copy of this form.
71. Email address

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