Pittsfield Charter Township
Department of Public Safety
6227 West Michigan Avenue, Ann Arbor, MI 48108
Phone: (734) 822-4911 Fax: (734) 944-0744
Website: www.pittsfield-mi.gov
Mandy Grewal, Supervisor
Pittsfield Township Police Department Ride-Along Program
Voluntary Assumption of Risk, Waiver of Liability and Indemnification Agreement
I, __________________________, HEREBY ACKNOWLEDGE that I have voluntarily applied to participate in the Pittsfield
Township Police Department Ride-Along Program. I have read, understood and agree to abide by the Ride-Along Rules
and Regulations regarding my required conduct and responsibilities with respect to the program. I understand that the
privilege and authorization which is granted to me by the approval of this waiver and indemnification agreement may be
revoked at any time. INITIAL: ________
I AM AWARE THAT POLICE WORK, BY ITS VERY NATURE, CAN AND WILL IN ALL PROBABILITY, INVOLVE
SOME DANGER due to many factors, including the possibility of high-speed chases, armed suspects, and potential
emotional trauma. I AM VOLUNTARILY PARTICIPATING IN THIS ACTIVITY WITH KNOWLEDGE OF THE DANGER
INVOLVED AND HEREBY ASSUME FULL RESPONSIBILITY FOR AND RISK OF BODILY INJURY, DEATH, OR
PROPERTY DAMAGE due to the negligence of the Township or otherwise resulting from any aspect of my voluntary
participation in the Pittsfield Township Police Department Ride–Along Program. INITIAL: _______
I HEREBY WAIVE, RELEASE, AND FOREVER DISCHARGE AND COVENANT TO HOLD HARMLESS FOR ALL
LIABILITY THE TOWNSHIP OF PITTSFIELD and any of their elected and appointed officials, 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 claims, damages, costs, liabilities, losses, causes of action, demands in law or in equity, resulting from the
negligence of the Township of Pittsfield and any of their elected and appointed officials, officers, agents or employees, any
and all other officers, agents, or employees, and all other persons, firms and corporation, or otherwise resulting from any
aspect of my voluntary participation in the Pittsfield Township Police Department Ride-Along program. INITIAL: ________
I FURTHER AGREE TO FULLY INDEMNIFY THE TOWNSHIP OF PITTSFIELD, the Pittsfield Township Police
Department, and any and all of their elected and appointed officials, officers, agents or employees from any and all third
party claims, damages, costs, liabilities, losses, causes of action, demands in law or in equity of any kind, resulting from acts
or omissions on my part at any time upon which I am a participant in the Pittsfield Township Police Department Ride-Along
program. INITIAL: ________
I HAVE CAREFULLY READ THIS AGREEMENT AND FULLY UNDERSTAND THAT IT IS AN AGREEMENT TO
ASSUME ALL RISKS AND TO RELEASE THE TOWNSHIP FROM ALL LIABILITY RESULTING FROM MY
PARTICIPATION IN THE RIDE-ALONG PROGRAM AND SIGN IT OF MY OWN FREE WILL. I warrant that no promise
or inducement has been offered, except as herein set forth, that this waiver 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. I further warrant that I am legally
competent to execute this document. I intend for this agreement to be binding to myself and my heirs, personal
representatives, next of kin, spouse, administrators, successors, and assignees.
Applicant Signature: ____________________________________________ Date: _____________________
Notary Signature: _______________________________________________ Date: ____________________
Matthew E. Harshberger
Director of Public Safety
Chief of Police
harshbergerm@pittsfield-mi.gov
(734) 822-4921
Sean Gleason
Fire Chief
gleasons@pittsfield-mi.gov
(734) 822-4926
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