Form

Citizen Ride Along

The Citizen Observer Program is designed to allow citizens a chance to gain a realistic view of the law enforcement operations within the Town of Vinton. This form is used to request a ride along with a uniformed patrol officer. The following information is required to begin the application process, which is limited to twice a year. Once this form is submitted, a department official will contact you about your request.
Full Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
License or SSN *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number
Occupation *
If student, name of school attending.
Are you participating in a student intern program? *

Yes No
Emergency Contact Name *

First Name Last Name

Emergency Contact Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Contact Phone *

- Area Code Phone Number
Have you ever been convicted of a felony or misdemeanor? If yes, explain below. *
Do you suffer from any medical condition that might affect your participation during the ride along? If so, please explain below. *
Please list at least three upcoming dates and times that you would like to conduct your ride along.
Ride Along *

- Month - Day Year
at
: Hour Minutes
Ride Along *

- Month - Day Year
at
: Hour Minutes
Ride Along *

- Month - Day Year
at
: Hour Minutes
Are you currently an applicant for the position of Police Officer with the Town of Vinton Police Department? *

Yes No

Applicant Disclosure
I, hereby authorize the Vinton Police Department to perform an independent background investigation pertaining to criminal history and motor vehicle transcript information. I understand that this inquiry is for the purpose of confirming the information contained within this application, along with ensuring the suitability and qualifications to participate in the Citizen Observer Program. I also understand that criminal history and motor vehicle information will be reviewed on a case-by-case basis and that certain convictions for criminal and/or traffic offenses could potentially cause the application to be denied and eliminate the applicant from any further participation in this program. *

I agree to these terms
I certify that I understand the requirements and responsibilities of participants in this program, and that I am aware of the potential risk involved with accompanying an officer during the performance of their duties. In consideration of the Vinton Police Department granting permission to enter in or upon any premises or vehicles which are under its actual care of constructive or passive control, I hereby waive all claims to damage or loss to my person or property which may be caused by an act, or failure to act, of the Vinton Police Department, its officers, agents, and/or employees. I assume the risk of all dangerous conditions in, upon or about the premises or vehicles and waive any and all notice of existence of such conditions. *

I agree to these terms
To affirm your agreement with these terms and conditions, please enter your full name. *

First Name Middle Name Last Name
Enter the message as it's shown *
Should be Empty:

Citizen Ride Along

Please list at least three upcoming dates and times that you would like to conduct your ride along.

Applicant Instructions

Applicant Disclosure