Form 1-12A

In consideration of the Town of Christiansburg allowing me to participate in an intern/observation program at the Christiansburg Police Department, I do hereby for myself, my heirs, executers, administrators and assigns, forever release and discharge the Town of Christiansburg and the Christiansburg Police Department, their officers, employees, and agents of and from any and all claims, demands, actions, cause of action, and suits at law or in equity for or on account of any accident, injuries, disabilities, physical and mental disease, death, property damage and all losses and expenses of any nature whatsoever that may be sustained by me as a result of my participation in the aforesaid program. It is my intention that this release shall, and the same hereby does fully and completely settle, satisfy and discharge all claims, demands, actions, causes of action, and rights of every nature and description against the Town of Christiansburg and the Christiansburg Police Department, their officers, employees and agents, arising from my participation in the aforesaid program.

All information, conversations, or documents I may be exposed to, whether obtained while participating in the observation program or gathered while doing any assigned project or research shall be confidential. I further understand and agree not to disseminate this information, either verbally or in writing. This is to include any aspect of any investigation or criminal incident or the mere existence of an arrest record of which I may have knowledge because of my involvement with the Christiansburg Police Department. I will not divulge any information acquired from the NCIC/VCIN terminal or any department file (arrest or otherwise) to any person not having a legal right to said information. The unauthorized dissemination by me or any information of the Christiansburg Police Department intern/observation program may subject me to criminal prosecution or civil action.

Observer Information

Observer Name:*

Telephone:*

E-Mail:*

Driver's License Number:*

Driver's License State*

Date of Birth:*

By checking this box, I authorize the Christiansburg Police Department to conduct any background check necessary, including criminal/driving history, to determine my eligibility to particpate in the program.*

Date:*

You will be contacted if you are selected to participate in an intern or observation program. The Christiansburg Police Department only allows one ride per person every six months. If you have participated in the observation program within the past six months, you will not be eligible at this time.

(If observer is under the age of 18, this form must be filled out at the Police Department by both the observer and a legal parent/guardian.)