Fill - Free fillable RANDOLPH COUNTY SHERIFF'S OFFICE CITIZENS ACADEMY APPLICATION (Randolph County) PDF form

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RANDOLPH COUNTY SHERIFF'S OFFICE

CITIZENS ACADEMY APPLICATION

APPLICANT INFORMATION

Full Name:

EMPLOYMENT INFORMATION

Current Employer:

EMERGENCY CONTACT(S)

Phone:

Employer:

Position:

Number of Children: Age(s):

Organization/Activity Name:

By clicking I ACCEPT using any device, means or action, I acknowledge that all the information on this

application is true and accurate to the best of my knowledge. I also understand that any

misrepresentation or falsification of information will result in my denial or removal from the academy.

ACKNOWLEDGEMENT

By signing below I acknowledge that all the information provided on this application is true and

accurate to the best of my knowledge. I also understand that any misrepresentation or falsification of

information will result in my denial or removal from the academy.

Signature

ELECTRONIC SIGNATURE OPTION

Time with Employer:

COMMUNITY INVOLVEMENT

Please list any community organizations you are a part of or community activities that you participate

in.

RANDOLPH COUNTY SHERIFF'S OFFICE

CITIZEN'S ACADEMY APPLICATION

FAMILY INFORMATION

Spouse Name:

Date of Birth:

I ACCEPT

day of , 20___

My commission expires:

a) I Assume full responsibility for any personal injury or damage to my person or property and I hereby waive

myself, my heirs, executors, administrators, or assigns, any and all claims, demands, actions, or causes of action

against Randolph County, the Randolph County Sheriff, its officers, agents and employees if whatever kind or

nature may arise in any manner by reason of injury or damage to my person or property or both while I am riding in

Sheriff’s Office vehicles, while observing any operation, while accompanying deputies of said agency in the

performance of their duties, or while participating in this program in any other manner; and

(b) I do hereby covenant and agree that I will never instigate and suit or action against Randolph County, the

Randolph County Sheriff’s Office, it’s officers, agents, or employees for damages or loss or injury of any kind for

or on account of any damages, loss or injury to my person or property or both which may arise in any manner while

I am riding in Sheriff’s Office vehicles, while observing and operation, or participating in this program in any other

manner; and

and employees, for any acts of conduct committed y me of whatever kind or nature whatsoever, while I am riding

in Sheriff’s Office vehicles, observing any operation, or participating in this program in any other manner and I

further agree to defend and pay any costs, judgments or attorneys’ fees resulting from said action or conduct so

committed by me;

RANDOLPH COUNTY SHERIFF'S OFFICE

Release and Indemnity Agreement

WHEREAS, I, the undersigned has voluntarily elected to ride as a passenger/observer in a patrol vehicle of the

Randolph County Sheriff's Office, Randolph County, North Carolina and to accompany officers of said agency

while engaged in the performance of their duties, to study and observe for his/her own benefit the functions and

operations of the Randolph County Sheriff’s Office and it’s personnel; and

WHEREAS, the undersigned, if an employee of the County of Randolph not regularly assigned to operate patrol

vehicles or any Law Enforcement Officer not involved in official Investigation, understands that said travel and

observation does not constitute job performance "arising out of" or "in the course of” employment for the purposes

of the Counties coverage Workman's Compensation; and

NOW THEREFORE, for and in consideration of the opportunity to ride with and observe a law enforcement

office/employee of the Randolph County Sheriff’s Office in the performance of his/her duties, I, the undersigned,

do hereby agree as follows:

Signature

Date

(d) This agreement holds harmless Randolph County, the Randolph County Sheriff’s Office, its officers, agents

and employees for any injury, including but not limited to claims for wrongful death, arising in any manner to me

while participating in this program.

I have read the foregoing waiver and covenant not to sue and understand that it constitutes a formal legal

document.

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Date

Sworn to and subscribed before me this

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RANDOLPH COUNTY SHERIFF'S OFFICE CITIZENS ACADEMY APPLICATION (Randolph County)

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