Release Of Claims Form (Page 2 of 2) in pdf

IN WITNESS WHEREOF, the Releaser has executed this release on the ____________ day of

___________________________, in the year 20____.

__________________________ ____

_______________________________

Print Name of RELEASER

Date of Birth of RELEASER

__________________________ _____

_______________________________

Driver’s License #

Address

__________________________________

Social Security #

City, State, Zip

Home Phone

_______________________

___________________________________

Signature of RELEASER

Email Address

: ____________________

Region/division you wish to ride: ________________

NOTE: if you are requesting approval for multiple ride-a-longs, please complete the

following:

I am requesting approval for multiple ride-a-longs for the period beginning ________________to

______________________________________. (Requests may not exceed (3) month time span).

SWORN before me this, the ________ day of ______________________, 20___.

_____________________________

________________________________

Notary Public for South Carolina

My Commission Expires

Instructions to the Releaser: Please complete this form and return it to the Desk Sergeant or

approved representative at the Richland County Sheriff’s Department. Upon the Sheriff’s

review/approval, you will be notified by a representative of the Richland County Sheriff’s

Department and arrangements will be made to coordinate your ride with a Deputy. You will need

to pick up a copy of your approved release form from a representative of the Richland County

Sheriff’s Department prior to your scheduled ride-a-long. This form must be given to the Deputy

you ride with prior to entering a Sheriff’s Department vehicle. Your identity will be verified by

the Deputy you are scheduled to ride with.

***************************ADMINISTRATIVE USE ONLY************************

APPROVED: ______________________________

DATE: ______________

LEON LOTT, SHERIFF of RICHLAND COUNTY

1. Background Check completed

___________________

2. Review/Approval by Sheriff

___________________

3. Coordinate with Releaser issued a copy of approved form

___________________

4. Ride-a-long scheduled for

_______________________ at

___________________

(date)

(time)

5. Region/Person notified ____________________________

___________________

(Date/time)

6. Copy of Release left at ____________________________

___________________

(Date/Time)

7. Note to Deputy participating in ride-a-long: review the above information and verify the

identity of the releaser. Obtain their copy of the release and file with your region upon

completion of ride.

Release Of Claims Form Page 2

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