WESTERN KENTUCKY UNIVERSITY
POLICE DEPARTMENT

RELEASE AND INDEMNITY AGREEMENT
(Ride-a-Long)

WHEREAS, ____________________________ has voluntarily elected to ride as a passenger in a Department vehicle of the Western Kentucky University Police and to accompany police officers of said department while engaged in the performance of their duties, to study and observe for his/her own benefit the functions and operations of the Western Kentucky University Police Department it's personnel; and

WHEREAS,
____________________________ desires to do so at his own risk and recognizing the possible and inherent danger to his/her person and property resulting therefrom; and

WHEREAS,
Western Kentucky University does not wish to be liable for any damage arising from personal injuries and/or property damage sustained;

NOW THEREFORE,
in consideration of the premises and other good and valuable consideration, the undersigned do hereby, for themselves, their heirs, executors, administrators, and/or personal representatives:
  1. Assume full responsibility for any personal injury or damage to the person or property of ___________________________ which may occur, directly, or indirectly, while in, on or about any such Police Department vehicle, the Police Department premises or any part thereof at the Western Kentucky University Police Department while in the performance of their duties.

  2. Fully and forever release and discharge Western Kentucky University and the State of Kentucky, its agents and employees, from any and all claims, demands, damages rights of action, or causes of actions, present or future, whether the same be know, anticipated or unanticipated, resulting from or arising out of ____________________________ being in, on or about any such Police Department vehicle, or at any or all premises and places aforesaid, or while accompanying any Police Officers of Western Kentucky University.

  3. Indemnify and hold harmless Western Kentucky University and the State of Kentucky, its agents and employees, for any acts or conduct of ______________________________ of whatever kind or nature whatsoever, while in the premises and places aforesaid, or while accompanying any such officer as aforesaid;

  4. Agree to defend and to pay costs or attorney's fees as a result of any action brought by or against Western Kentucky University or the State of Kentucky, its agents and employees, for any acts of conduct of _____________________________ of whatever kind or nature whatsoever, while in, on or about any such Police Department vehicles, or at any or all of the premises and places aforesaid, or while accompanying any such police officer as aforesaid; and

  5. Agree that is the intent of the undersigned that this Release and Indemnity Agreement be in full force and effect at any time after the execution hereof.

PLEASE PRINT ALL INFORMATION (Except signature blocks)

_______________________________________
(Signature)
______________________________________
(Print Name)

______________________________
(Social Security #)
_______________________________
(Date of Birth)
______________________________
(Spouse/Mother/Father)

__________________________
(Home Address)
_____________________________
(City)
_____________
(State)
_________________
(Zip)

__________________________________________________________________________________________________
(Employer)

__________________________
(Work Address)
_____________________________
(City)
_____________
(State)
_________________
(Zip)

_____________________________
(Home Phone #)
_____________________________
(Work Phone #)
____________________________
(Cell Phone #)

Dated at Bowling Green, Kentucky, this _____________ day of

____________________, 20______, at _______________ o'clock am/pm.

Witness Signature: _____________________________________________


The following information must be completed in order to process request.

Date Requested to Ride _________________________ Time Requested to Ride ______________________

Officer Requested to Ride with ________________________________________________

REASON FOR REQUEST FOR RIDE-A-LONG
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________


For Departmental Use Only:

Records Check _____________________________________
Officer Assigned ___________________________________

_________________________________________________

Date(s) __________________________________________

By ______________________________________________

Time Period _______________________________________

APPROVED BY:
Name: ____________________________________________ Date: __________________________________

(Revised: 09/25/07)