WILSON POLICE DEPARTMENT
GENERAL RELEASE FORM
KNOW ALL MEN BY THESE PRESENT: That I, __________________________,
request that I be allowed to accompany police officers of the City of Wilson, North
Carolina, on patrol duty, with the understanding that I assume the risk for any and
all liability arising from such activity and I do hereby agree to release and forever
discharge its servants, agents and employees, and its successors and assigns from
any and all claims, demands, rights, and causes of actions of whatsoever kind and
nature arising from and by reason of any all known and unknown, foreseen and
unforeseen bodily and personal injuries, damage to property, and the consequence
thereof, and resulting from and to result, from any occurrence, accident, event or
other happening arising out of the grant of and the use of such permission by me,
hereby expressly releasing the aforesaid from any and all liability.
IN WITNESS WHEREOF, I have hereunto set my hand and seal on the________ day of _____________, 20___.
STATE OF NORTH CAROLINA)
CITY OF WILSON )
I hereby certify that on this______ day of ________________20___, before me, a Notary Public, in and for the aforesaid State and City personally appeared_________________________________, personally well known to me (or satisfactorily proven) to be the person described in and who executed the above instrument and be acknowledged to me that he executed the same.
My Commission Expires on:___________________________________________________
WPD # 65 Rev. 2/01