Mj New Ral Form - Ride-Along Program Application Form - Sacramento County Sheriff'S Department
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2SACRAMENTO COUNTY SHERIFF’S DEPARTMENT
Ride-Along Program Application Form
RAL # (For SSD Use only)
XREF (For SSD Use Only)
IDENTIFYING INFORMATION
NAME (LAST, FIRST MIDDLE)
DATE
ALIAS/ADDITIONAL NAMES
ADDRESS
CITY
ZIP
TELEPHONE
NAME OF EMPLOYER
OCCUPATION
EMAIL ADDRESS
WORK ADDRESS
CITY
ZIP
TELEPHONE
SEX
DESCENT
BIRTHDATE
CITY/STATE OF BIRTH
DRIVER’S LICENSE # / STATE
EMERGENCY INFORMATION
IN AN EMERGENCY NOTIFY (LAST NAME, FIRST NAME)
RELATIONSHIP
ADDRESS
CITY
ZIP
TELEPHONE
BLOOD TYPE
ALLERGIES
MEDICATIONS
PHYSICAL CONDITION/AILMENT(S) YOU WISH TO DISCLOSE IN THE EVENT OF A MEDICAL EMERGENCY (OPTIONAL)
INSTRUCTION OR INFORMATION TO TREATING PHYSICIAN (OPTIONAL)
SECURITY CLEARANCE INFORMATION
HAS APPLICANT EVER BEEN ARRESTED?
YES
NO
IF YES, LIST DATE(S), OFFENSE AND JURISDICTION
YES
NO
HAS APPLICANT EVER BEEN ADMITTED TO A PSYCHIATRIC TREATMENT FACILITY?
YES
NO
HAS APPLICANT EVER BEEN DETAINED FOR A MENTAL CONDITION PURSUANT TO W&I § 5150?
LIST DATE(S) AND CIRCUMSTANCES
ELIGIBILITY INFORMATION
HAS APPLICANT PARTICIPATED IN THE
DATE LAST
RECOMMENDED BY: (OR SELF REQUEST)
RIDE ALONG PROGRAM IN THE PAST?
PARTICIPATED
NO
YES
WHY WOULD YOU LIKE TO PARTICIPATE IN THIS PROGRAM? (BRIEF SUMMARY)
NO
YES
ANY RELATIVES OR CLOSE FRIENDS CURRENTLY IN SACRAMENTO COUNTY CUSTODY?
_____________________________
NAME________________________________
LOCATION
RESIDE/WORK IN DISTRICT
ALLIED OR PARTNER AGENCY
LAW ENFORCEMENT EMPLOYEE/RETIREE
FAMILY MEMBER OF DEPT. EMPLOYEE
GOVERNMENT OFFICIAL
OTHER (explain):
THIS APPLICATION IS NOT TO BE REPRODUCED FOR USE BY AN APPLICANT
OVER
(
)
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