NEW ALBANY POLICE DEPARTMENT - New Albany, Ohio

Addendum C
Request of Civilian Observer in Cruiser
Requestor’s Name:
Reason for request:
Phone Number:
Parent or Legal Guardian
(if under 18 Y.O.A.):
OLN or SSN:
Being of legal age (18), if not, with the written consent of my parent(s) or legal guardian(s), do hereby make a written
request of permission to the New Albany Police Department and the City of New Albany, Ohio, to ride as a civilian on
the above requested date and time.
During this ride-a-long, I will not attempt to view any on screen contents of the police laptop in the cruiser. The
information contained on this computer is very confidential. If this rule is broken, I realize that I can be
banned from the cruiser at that time and may never be permitted to ride-a-long again.
Release:
Known to all men by these presence, that I
being of legal age
(Requestor – Print Name)
(18), if not, with the written consent of my parent(s) or legal guardian(s), myself, my heirs, assigns, executors and
administrators, forever discharge the New Albany Police Department, Chief of Police, the officers and the City of New
Albany, the mayor, the prosecutor, and any and all officials of the City of New Albany, Ohio and the State of Ohio,
which may be affected from any and all action, causes of actions, claims, demands, cost, loss of service, expenses and
compensation, on account of or growing out of riding or being with any officer as a civilian observer, on the date of
request, and do hereby covenant with said police department, chief of police, officer, mayor, prosecutor, and the City
of New Albany, Ohio, and the State of Ohio, which may be affected, to indemnify and save them harmless from all
actions, causes of actions, claims, demands, cost, loss of service, expenses and compensations on account of, or in any
way growing out of said incident, from the date of these presence.
Signature - Requestor
Date
Signature – Parent or Guardian (if required)
Date
FOR POLICE USE ONLY
DATE:
REQUEST TAKEN BY:
SUPERVISOR: APPROVED DENIED DATE:
ASSIGNED TO:
PD-03-115
Revised January 4, 2011