City of Peoria

Fire Department
8401 West Monroe Street
Peoria,  AZ  85345

WAIVER OF LIABILITY
CITIZEN OBSERVER PROGRAM

Name: _______________________________________________ 

Address:  ____________________________________________

 City/State/Zip:             ____________________________________________

Phone:
 ________________________________________


DOB:  ______________________________
(Must be at least 18 years of age)

Valid ID:  ___________________________________
(Attach Copy Valid ID)
Date Desired:  ______________________________
Observation Hours:  Between 0800 & 2000 hrs
Station:  _____________________________
Shift:  _______________________________
In consideration of being permitted to ride on the vehicle(s)/apparatus of the City of Peoria Fire Department, I hereby release and agree to hold harmless the said Fire Department and the City of Peoria, its employees, agents and representatives from any and all liability for any damages or injury which I may receive while riding on said vehicle(s)/apparatus or received accompanying Peoria Fire Department firefighters unless such damages or injuries are caused by the negligence of the City of Peoria, it’s employees, agents or representatives.

I hereby acknowledge that this release of liability and agreement given by me to the said City of Peoria, its employees and agents, shall apply as to any right of action that occur to myself, my heirs and my personal representatives.  Further, I agree to assume all risks in riding in the said Peoria Fire Department vehicle(s)/apparatus and in accompanying its firefighters and am fully aware of the dangers involved.

Do you have any handicap or special needs which may require special accommodations?  ( Yes  (  No 
Explain: _________________________________________ ___________________________________________________________________________________________________________________________________________________
DISCLAIMER:  Company Officers will not/can not be held responsible for determining specific times the crew(s) will return to quarters.  Any personal business, obligations or commitments that require attention during such time of observation must be completed prior to observer riding or ride a long must be rescheduled.

Observer Signature:  __________________________________________      Date:  _______________

Authorizing Company Officer:  _________________________________      Date:  _______________

Comments:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Fire Department Community Services 
– Record Retention
Observer - Copy
FD #119
Rev. 6/12/02
RULES:

* Observer(s) shall wear seat belt at all times while riding in City of Peoria vehicle(s)

* Observer(s) shall dress in a manner consistent with safety and public image.  Prohibited dress includes:  open toe shoes, sandals, high heels, shorts, tank tops, garments with offensive messages, garments that are excessively loose, and/or excessive loose jewelry.
 
* Observer(s) must be at least 18 years of age and have no physical limitations of a nature that would jeopardize the safety of the individual or others.

* Observer(s) are limited to the following ride a long(s) per year:

* General observer(s) . . . . . . . . . . . . . . . . . . . . . . . . . . . Two (2)
* Emergency Service Personnel . . . . . . . . . . . . . . . . . . . .  Four (4)
* Base Station Doctors, nurses or others who must ride to evaluate Peoria 
     Fire department operations . . . . . . . . . . . . . . . . . . . . . .  As needed
* Collegiate Mentoring Program . . . . . . . . . . . . . . . . . . . .  Twelve (12)


* Hours shall be limited:

* Emergency service observation hours shall be limited to 0800 – 2000 hours
* Under “NO” circumstances shall observer(s) stay overnight at Fire stations.
* Observer(s) restricted from entering any sleeping quarters at the Fire stations

* Observer(s) may accompany Fire department personnel into residences/businesses to observe, however, observer(s) shall be prepared to remain outside if conditions warrant such action(s) for safety and/or privacy reasons.

* Observer(s) shall not attempt to assist firefighters with any aspect of routine duties or emergency operations.  Observer(s) shall remain in cab during initial stages of any fire fighting activity to eliminate impeding operations and safety concerns.

* Observer(s) shall follow the direction of the apparatus Company Officer or designee at all times.  Observation privileges may be revoked or suspended for failure to comply with Fire department policy(s), procedure(s) or direction(s).





FD#119 – Ref MP104.02
Rev. 6/12/02