Western Kentucky University Police Police Explorer Participant Form Name ________________________________________________________

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Western Kentucky University Police
Police Explorer Participant Form
Name ________________________________________________________
First
Middle
Last
Drivers License Number _________________
Age ______
Date of Birth ___/___/___
Social Security Number _____________________
Local Address __________________________________________________
Street
City
State
Zip
County
Permanent Address _____________________________________________
Telephone Number ___________________________________________________
Local
Home
Cellular
Email Address ______________________________________________________
IN CASE OF EMERGENCY (CONTACT)
Name _________________________________________________________
Address
___________________________________________________
Telephone
___________________________________________________
Relation
___________________________________________________
Hometown Police Agency ________________________________________
Have you ever been convicted of a criminal offense? _______ Date _______
Location/Police Agency/Court ____________________________________
Charge/Offense _____________________ Disposition ________________
Comments ____________________________________________________
_____________________________________________________________
PERSONAL REFERENCE
Name _______________________ Telephone Number ________________
Address ______________________________________________________
Employment ___________________________________________________
Employer
Position
Phone Number
WESTERN KENTUCKY UNIVERSITY
POLICE DEPARTMENT
RELEASE AND INDEMNITY AGREEMENT
WHEREAS, ______________________ has voluntarily elected to participate in the
Western Kentucky University Police Explorer Post and to accompany police officers of said
department while engaged in the performance of their duties, to study and observe for his
(or her) own benefit the functions and operations of the Western Kentucky University
Police Department and its personnel; and
WHEREAS, _____________________ desires to do so at his on risk and recognizing the
possible and inherent danger to his person and property resulting therefrom; and
WHEREAS, Western Kentucky University does not wish to be liable for any damage
arising from personal injuries and/or property damage sustained;
NOW THEREFORE, in consideration of the premises and other good and valuable
consideration, the undersigneds do hereby, for themselves, their heirs, executors,
administrators, and/or personal representatives:
1. Assume full responsibility for any personal injury or damage to the person or
property of ___________________ which may occur, directly, or indirectly,
while in, on or about any such Police Department vehicle, the Police
Department vehicle, the Police Department premises or any part thereof at the
Western Kentucky University Headquarters Building or while accompanying
any Police Officers of the Western Kentucky University Police Department
while in the performance of their duties.
2. Fully and forever release and discharge Western Kentucky University and the
state of Kentucky, its agents and employees, from any and all claims,
demands, damages rights of action, or causes of actions, present or future,
whether the same be known, anticipated or unanticipated, resulting from or
arising out of _________________ being in, on or about any such Police
department vehicle, or at any or all premises and places aforesaid, or while
accompanying any Police Officers of Western Kentucky University.
3. Indemnify and hold harmless Western Kentucky University and the State of
Kentucky, its agents and employees, for any acts or conduct of
_________________ of whatever kind or nature whatsoever, while in, the
premises and places aforesaid, or while accompanying any such officer as
aforesaid;
4. Agree to defend and to pay costs or attorney’s fees as a result of any action
brought by or against Western Kentucky University or the State of Kentucky,
its agents and employees, for any acts of conduct of __________________ of
whatever kind or nature whatsoever, while in, on or about any such Police
Department vehicles, or at any or all of the premises and places aforesaid, or
while accompanying any such police officer as aforesaid; and
5. Agree that it is the intent of the undersigned that this Release and Indemnity
Agreement be in full force and effect at any time after the execution herof.
__________________________________________________________________
Signature
Print Name
__________________________________________________________________
Social Security
Date of Birth
Spouse/Mother/Father
__________________________________________________________________
Home Address
City
State
Zip
__________________________________________________________________
Employer
__________________________________________________________________
Work Address
City
State
Zip
__________________________________________________________________
Home Phone Number
Work Phone Number
Cell Number
Dated at Bowling Green, Kentucky, this _________ day of ________, 20____ at
____________ O’clock AM/PM
WITNESS: ________________________
__________________________
Records Check ___________________
Officer Assigned __________________
By _____________________
Date (s) _________________________
Time Period ______________________
Reason for Request
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Approved
By:_____________________________________________________________
Name
Date
WESTERN KENTUCKY UNIVERSITY POLICE
EXPLORER POST
PARENT PERMISSION FORM
__________________________ has my permission to participate in the Western
Kentucky University Police Explorer Post and any activities or trips associated with the
Post.
I know of no health or fitness restriction(s) that preclude participation. In the event of
illness or injury occurring to my son or daughter while involved in this activity, I consent
to X-Ray examinations, anesthesia, medical, or surgical diagnostic procedures or
treatment that is considered necessary in the best judgment of the attending physician and
performed by or under the supervision of a member of the medical staff of the hospital
furnishing medical services. (It is understood that in the event of a serious illness or
injury, reasonable efforts to reach me will be attempted.)
Signature of Parent _________________________________ Date ______________
Signature of Participant _____________________________ Date ______________
The following numbers are where I can be reached:
Home ___________________________
Work ___________________________
Cell ____________________________
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