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2. Name (Last, First, MI)*
3. DOB: *
   DOB:
5. Street Number
6. Street Name
7. Street Type
8. Apt #
10. City
11. State
12. Zip
14. Phone Number: *
15. Email:*
16. Do you need accommodation? *
    -- Select One --YesNo
18. If yes, describe:
20. Requested Date: *
    Requested Date:
21. Requested Time:
    Requested Time: Start Time

    —

    Requested Time: End Time
23. Reason(s) for Ride Along:
25. WAIVER
    I acknowledge that I am riding with the Fort Lupton Police Department (FLPD) of my own free choice as a citizen observer. In consideration of being permitted to ride in FLPD vehicles, I hereby assume all risk of personal injury or death and to also release and agree to hold harmless the City of Fort Lupton, the FLPD, their employees and their agents from any and all liability for any damage or injury that I receive while riding in the FLPD vehicles or from any cause whatsoever while accompanying FLPD police officers, including any City responsibility for the act of others. This assumption of risk release of liability and agreement given apply to any right of action that might arise to me, my heirs, and my personal representatives. Further, I agree to obey directions of the officer while riding in FLPD vehicles and accompanying FLPD officers in the performance of their duties.
27. I certify that I have read and understand the waiver. *

    1. Yes
    2. No
28. Print Name: *
30. JUVENILE WAIVER
    If the applicant is under the age of eighteen (18) years of age, I as parent, guardian, or legal custodian of the minor signing the WAIVER of liability as stated above, do hereby consent to the terms therein stated on behalf of myself and the minor.
32. I certify that I have read and understand the waiver as a legal guardian.

    1. Yes
    2. No
33. Print Name:
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field