RIDE ALONG PROGRAM
CAMPUS PUBLIC SAFETY OFFICE
Read and sign both sides of this form. Turn it into the front counter of the Portland State University Campus
Public Safety Office- Shattuck Hall, room 148. After four business days, call 503-725-4009 to find out the
status of your ride-along. It is your responsibility to call. If you have already arranged your ride through an
officer, indicate this below, fill out the rest of the form and have the officer complete the bottom section.
PLEASE PRINT
Today’s date:
Name:
(FIRST)
(MIDDLE)
(LAST)
Address:_________________________________________________________________________________________
Home Telephone: _________________________________ Cellular Phone:____________________________________
Employer:_______________________________________________________ Telephone: ________________________
Social Security # :
Drivers License # :
Date of Birth:
State of License Issue:
List any current medical problems for which you are being treated, past medical problems of which we should be aware,
or any potential physical difficulties, which might interfere with entry and exit from a patrol vehicle:
List any medications you are currently taking:_____________________________________________________________
List two people who can be notified in case of emergency:
1.
(NAME)
(RELATIONSHIP)
(ADDRESS)
(TELEPHONE)
(NAME)
(RELATIONSHIP)
(ADDRESS)
(TELEPHONE)
2.
Family Physician:
(NAME)
(TELEPHONE)
THIS SECTION NEEDS TO BE COMPLETELY FILLED OUT AT THE TIME OF APPLICATION
______ I am
_____ I am not
currently scheduled to ride with officer ____________________ on (date) __________________ at (time) ____________.
Statement of purpose of observer ride:
The Campus Public Safety Office requires a criminal background check to be granted by the applicant in order to
establish security clearance for a rider. Your signature indicates your knowledge and consent for this background check.
Signature:
Parent Signature (17 and younger):
Date:
******************************************************************************************************************************************
The following information is requested for statistical purposes only. The information is voluntary. If you prefer not to
provide it, there will be no effect on your observer status.
I prefer not to provide the information requested.
Caucasian _________ African Am.__________ Native Am. _________ Latino/a Am._________ Asian Am. _________
Sex: ______________
Age:
_____ Under 21
_____ 21-39
_____ 40-70
FOR INTERNAL OFFICE USE ONLY
Background completed by: ________________________ Approved/Denied on: _______________________
Date assigned:__________________________________ Time assigned: ___________________________
Officer assigned: ________________________________ Supervisor’s Signature: ____________________
Initiated by: ___________ Prev/Ed:_________ Patrol: _________ CPA: __________ Applicant:__________
RELEASE AND AGREEMENT OF INDEMNIFICATION
This document is a Release and Agreement of Indemnification entered this
(MONTH)____________________________
(DAY)_______________
day of
, 20(YEAR)___________, between (YOUR NAME) ____________________________________________
hereinafter referred to as the Undersigned, and Portland State University, State of Oregon hereinafter
referred to as PSU.
RECITALS
The Undersigned knows and understands the inherent risks to himself/herself in riding with and accompanying a
Campus Public Safety Officer; and the Undersigned does not wish to hold Portland State University, its Director of
Public Safety, Campus Public Safety Officers, employees, agents, representatives, or other Portland State
University personnel responsible for any harm or injury.
The Undersigned wishes to deliberately and voluntarily expose himself/herself to all inherent risks and to
personally assume the risk of any injuries or damage arising out of or occurring while preparing for, departing
from, or riding with or accompanying a Campus Public Safety Officer in a Campus Public Safety Office patrol
vehicle while in the performance of the officer’s duties.
FORM
ADULT FORM
The PSU is willing to allow the Undersigned the opportunity to ride with and accompany a
Campus Public Safety officer while in the performance of the officer’s duties, such ride being for the purpose of
observation.
NOW, THEREFORE, the PSU agrees to make available to the Undersigned an opportunity to ride as an observer
in the Campus Public Safety Office patrol vehicle with a Campus Public Safety Officer of Portland State
University.
The Undersigned, in consideration of the benefit to him/her, releases from any and all liability and agrees to
indemnify and to save and hold harmless PSU, the Director and Lieutenant, all Campus Public Safety Officers,
the Campus Public Safety Office, and all agents and personnel o, from any and all liability, cost, expense, claim,
or damage which might otherwise be claimed by the Undersigned or his/her heirs, successors, or assigns, on
account of any injury to the person or property of the Undersigned of whatsoever kind arising directly or indirectly
out of this observation ride, including but not limited to:
(1)
(2)
(3)
Automobile accident, no matter which driver is at fault;
Any injuries arising from any fight, brawl, altercation, riot, or other incidents;
Any other injuries which may be sustained by the Undersigned at any time while riding or
accompanying a Campus Public Safety Officer.
It is not the intention of the Undersigned to, and the Undersigned does not, release any other person who inflicts
any injury to the person or property of the Undersigned while the Undersigned is participating as an observer.
The Undersigned further states that he/she has carefully read the foregoing Release and Agreement, and
understands the content thereof and signs this Release as his/her free act.
(RIDER SIGNATURE)
(DPS SUPERVISOR SIGNATURE)
(DATE)
(DATE)
IF THE APPLICANT IS 17 YEARS OF AGE OR YOUNGER:
(PARENT SIGNATURE)
(DATE)