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FSPD FORM #101Fort Smith Police DepartmentWaiver of LiabilityCivilian Ride Along CPA Training L/E Training OtherI (print full name), ___________________________, (address)___________________________, requestpermission of the Fort Smith Police Department to participate in and/or to observe the activities of on dutyFort Smith police officers. In consideration of such permission, I agree: to follow all instructions given byany officer; to accept full responsibility for my own safety and well-being; to waive my rights or claims in theevent of any accident, incident, or injury, including, but not limited to those that may be the result ofnegligence on the part of one or more employees of the Fort Smith Police Department. Furthermore, Irelease the City of Fort Smith, its officers and directors, and all employees of the City of Fort Smith fromany and all liability for any injury or loss I might sustain while participating in and/or observing policeactivities. I understand the physical nature of and the inherent danger of police activities, including trainingtherefore, and I assume all of the risks associated with participating in and/or observing them. I alsounderstand that a criminal record and/or warrant check (and, if applicable, a physician’s statement) shall berequired before I am allowed to participate in and/or to observe police activities. I am requesting thisprivilege because: ____________________________________________. In the event of an accident orinjury, I authorize the Fort Smith Police Department to take me to ___________________________and tonotify (name) ____________________________ at (phone) _______________. Before signing this waiver,I have either consulted an attorney of my choice or have knowingly elected not to do so.Signature___________________________________Date_______________CPA or LFS: Y or NDOB___________ Male/FemaleRace____ SSN ____________________ Ph#:__________________Signature of Parent/Guardian (if < 18 years of age) ________________________ Date______________FOR RIDE ALONG APPLICANTS ONLYDate ride requested_________________ Date of previous ride ____________________Citizen’s Police Academy graduates, Leadership Fort Smith graduates, or similar educational participantswill be permitted to ride once every ninety days. All other persons may ride once a year.Please circle requested shift. Troop 1 Troop 2 Troop 35am to 3pm 1pm to 11pm 9pm to 7am6am to 4pm 2pm to 12am 10pm to 8am_____________________________________________________________________________________FSPD SupervisorApproved or Denied (circle) by: __________________________ Date: ___________________Officer Assigned: _________________________________________If denied, notified by: _________________ Date: ___________ Reason: _________________________