| RIDE-ALONG REQUEST Date Submitted_____________________ Please PRINT the following: Print Name___________________________________________________________________________________ (First) (Middle) (Last) Address_____________________________________________________________________________________ (Number & Street) (City) (State) (Zip) Work Phone Number (____)_____________________ Home Phone Number(____)_______________________ Date Of Birth_________________________________ Age __________________________________________ Driver License Number_________________________________________________________________________ (Type) (Number) (State) Occupation___________________________________________________________________________________ Date of Ride-along_________________________ Hours ____________ AM/PM TO_______________ AM/PM Request to ride with Officer______________________________________________________________________ Relationship to Officer (if any) ___________________________________________________________________ Reason for ride-along___________________________________________________________________________ Parental Consent (if participant is under 18) is hereby given_____________________________________________ HAVE YOU PREVIOUSLY RIDDEN WITH THE DACONO POLICE DEPARTMENT?______________________ Date of Last ride-along _______________________________ Note: A request should be submitted ten (10) days prior to the ride. You will be contacted after the request is processed and approved to confirm the date and hours of your Ride-Along. SIGNATURE OF APPROVAL / DENIAL Date_________________________ ____________________________________ Supervisor |
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