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SAN DIEGO POLICE DEPARTMENT (The City of San Diego)

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SAN DIEGO POLICE DEPARTMENT
Page 1 of 2 Police Legal (PEF) 6/14/2010
RIDE ALONG REQUEST FORM
Date Received Home Phone Work Phone
Name DOB
Home Address
STREET CITY/STATE ZIP
Business Address
STREET CITY/STATE ZIP
Occupation Driver’s Lic/ID SS#
Division Assigned Shift Desired First Ride Along: Y / N
Reason Request Received by
AUTHORIZATION FOR MEDICAL TREATMENT
I understand and agree that the City of San Diego does not, and will not, provide medical coverage for
me/my child, and I WILL BE RESPONSIBLE FOR ANY MEDICAL COSTS INCURRED as a
result of participation in the activity. I give authorization to a physician or surgeon, licensed under the
provisions of the Medical Practice Act, to give me /my child, ________________________________,
care and/or emergency medical treatment when necessary.
________________________________ ______________________________ _______
Participant or Parent (Print Name) Signature Date
COORDINATOR USE
Routed to _________________________ Date _______________ Watch ___________
Ride Along File Checked: Y / N Age Waiver: Y / N
Captain Waiver: Y / N Captain’s Signature _____________________________________
Records Check Results ____________________Warrant Check Results ___________________
SUPERVISOR USE
Officer Assigned ____________________ If Ride Along Denied, Why?____________________
OFFICER USE
Officer Assigned __________________ Contact Date __________ Date of Ride Along _______
Obtain ID/Log Info. __________ Complete waiver _______ Advise Communications _______
Advise of Witness Obligation ___________ Advise of Safety Precautions ________
Officer’s Comments Attached: Y / N
SAN DIEGO POLICE DEPARTMENT
Page 2 of 2 Police Legal (PEF) 6/14/2010
RIDE-ALONG WAIVER AND RELEASE OF LIABILITY
For and in consideration of the permission granted to me, ____________________________________
(or to my child, ____________________________________), by the City of San Diego to accompany
officers of the San Diego Police Department while on patrol, on ____________ (date), I agree that:
1. Participation in the Ride-Along program is voluntary and I /my child freely choose to
participate;
2. I acknowledge that participation may include inherently dangerous activities. I understand that
police patrol involves, on occasion, extraordinary circumstances which may be hazardous to
person or property, and I assume and accept all risks associated with participation, including
bodily injury or death, or other loss, including damage to property;
3. Understanding that participation in the activity could involve potential risks of harm, not
limited to those specified above, I DO RELEASE, HOLD HARMLESS AND PROMISE
NOT TO SUE THE CITY OF SAN DIEGO AND THE SAN DIEGO POLICE
DEPARTMENT, ITS OFFICERS, EMPLOYEES, AGENTS, AND VOLUNTEERS,
WITH RESPECT TO ANY AND ALL SUCH INJURY OR LOSS, except that injury or
loss which results from the sole gross negligence or willful or wanton misconduct of one of
those individuals;
4. I FURTHER AGREE TO INDEMNIFY AND DEFEND THE CITY OF SAN DIEGO AND
THE SAN DIEGO POLICE DEPARTMENT, its officers, employees, agents, and volunteers,
FROM AND AGAINST ANY AND ALL LIABILITY INCURRED as a result of or in any
manner related to participation in this activity.
5. I understand that while on patrol I/my child may become a material witness to incidents or
events which form the basis for a criminal or civil proceeding. In this event, I/my child may be
required by subpoena to testify as a witness.
I AM AWARE THAT THIS CONTRACT IS LEGALLY BINDING AND THAT I AM
RELEASING LEGAL RIGHTS BY SIGNING IT.
I acknowledge by my signature that I have read and understand the terms that are set forth in this
agreement. I have entered into this agreement freely and without duress.
________________________________ ______________________________ _______
Participant or Parent (Print Name) Signature Date
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SAN DIEGO POLICE DEPARTMENT (The City of San Diego)

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Completed 16 July 2020

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