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___.


                        Participant  Signature:________________________________________




                                                         )  ss

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.



                                      NOTARY PUBLIC:__________________________________________________________

                                                                                                                                                                                                                      My Commission Expires on:___________________________________________________                                                                                     


                                                                                                                                                 WPD # 65 Rev. 2/01