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2. 
4. APPLICANT INFORMATION
6. Full Name
8. Preferred Called Name
9. Driver's License State and Number
11. Date of Birth
12. SSN (last 4)
14. Address
16. City
17. State
18. Zip Code
20. Phone Number
22. Email Address
24. EMPLOYMENT INFORMATION
26. Current Employer
28. Address
30. City
31. State
32. Zip Code
34. Phone Number
36. Job Title
38. Time with employer
40. EMERGENCY CONTACTS
42. Name
44. Address
46. City
47. State
48. Zip Code
50. Relationship
52. Phone Number
54. Name
56. Address
58. City
59. State
60. Zip Code
62. Relationship
64. Phone Number
66. FAMILY INFORMATION
68. Spouse Name
70. Date of Birth
72. Phone Number
74. Employer
76. Position
77. Time with employer
79. Number of Children and ages:
81. COMMUNITY INVOLVEMENT - Please list any community organizations you are a part of or community activities that you participate in.
83. Organization/Activity Name:
85. Acknowledgement*

    By selecting 'I agree' ,  I acknowledge that all the information provided on this application is true and accurate to the best of my knowledge.  I also understand that any misrepresentation or falsification of information will result in my denial or removal from the academy. 

    1. I accept
    2. I do not accept
87. RANDOLPH COUNTY SHERIFF'S OFFICE

    Release and Indemnity Agreement

89. WHEREAS, I, the undersigned has voluntarily elected to ride as a passenger/observer in a patrol vehicle of the Randolph County Sheriff's Office, Randolph County, North Carolina, and to accompany officers of said agency while engaged in the performance of their duties, to study and observe for his/her own benefit the functions and operations of the Randolph County Sheriff’s Office and its personnel; and                                

           
     WHEREAS, the undersigned, if an employee of the County of Randolph not regularly assigned to operate patrol vehicles or any Law Enforcement Officer not involved in official Investigation, understands that said travel and observation does not constitute job performance "arising out of" or "in the course of” employment for the purposes of the Counties coverage Workman's Compensation; and

     

    NOW THEREFORE, for and in consideration of the opportunity to ride with and observe a law enforcement office/employee of the Randolph County Sheriff’s Office in the performance of his/her duties, I, the undersigned, do hereby agree as follows:

    (a)I Assume full responsibility for any personal injury or damage to my person or property and I hereby waive myself, my heirs, executors, administrators, or assigns, any and all claims, demands, actions, or causes of action against Randolph County, the Randolph County Sheriff, its officers, agents, and employees if whatever kind or nature may arise in any manner by reason of injury or damage to my person or property or both while I am riding in Sheriff’s Office vehicles while observing any operation while accompanying deputies of said agency in the performance

    (b)I do hereby covenant and agree that I will never instigate any suit or action against Randolph County, the Randolph County Sheriff’s Office, its officers, agents, or employees for damages or loss or injury of any kind for or on account of any damages, loss or injury to my person or property or both which may arise in any manner while I am riding in Sheriff’s Office vehicles, while observing and operation, or participating in this program in any other manner; and

    (c)I do hereby indemnify and hold harmless Randolph County, the Randolph County Sheriff’s Office, its agents, and employees, for any acts of conduct committed y me of whatever kind or nature whatsoever, while I am riding in Sheriff’s Office vehicles, observing any operation, or participating in this program in any other manner and I further agree to defend and pay any costs, judgments or attorneys’ fees resulting from said action or conduct so committed by me;

    (d)This agreement holds harmless Randolph County, the Randolph County Sheriff’s Office, its officers, agents, and employees for any injury, including but not limited to claims for wrongful death, arising in any manner to me while participating in this program.

    
    I have read the foregoing waiver and covenant not to sue and understand that it constitutes a formal legal document.

91. First Name
92. Last Name
94. Signature

    
    _______________________________________________________________

96. Sworn to and subscribed before me this _____________ day of ____________________________, _________.

    
    

    
    

    __________________________________________________________Notary

    My Commission Expires: _____________________________________________

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98. 1. Receive an email copy of this form.
99. Email address

    This field is not part of the form submission.

100. Submit

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