Ride-A-Long Waiver

Please complete this form to request permission for a ride-a-long with an 杏吧原创police officer. Requests will consider scheduling allowance and officer availability.

PLEASE ALLOW TWO DAYS FOR PROCESSING.
Your request is not approved until you are notified by UPD.

Name Name First Last
Age
Today's Date Today's Date / MM / DD YYYY
Date wish to do ride-a-long.
Must be at least 3 days from today. Date wish to do ride-a-long.
Must be at least 3 days from today. / MM / DD YYYY
Time wish to begin ride-a-long Time wish to begin ride-a-long : HH MM AM/PM
Time wish to end ride-a-long Time wish to end ride-a-long : HH MM AM/PM
Purpose of request (explain in detail):
I agree that in consideration of being granted permission
for the purpose stated, I do hereby release, remise and forever discharge the Board of Trustees, Eastern Illinois University, its employees, agents and officers from any liability whatsoever and will hold each and all harmless from any and all claims, demands, suits, actions and causes of action which may now or anytime in the future be asserted by the undersigned or any third party in connection with my presence while in the police vehicle on the day and time indicated above.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Campus Address Campus Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
IF UNDER 18, WAIVER MUST ALSO BE SIGNED BY PARENT OR GUARDIAN.
Parent or Guardian Name Parent or Guardian Name First Last
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Parent or Guardian Address Parent or Guardian Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Parent or Guardian Phone Parent or Guardian Phone - ### - ### ####