Franklin County Sheriff

Seniors And Law Enforcement Together

Name
Address
City
State
Zip
Phone
Date of Birth
Age
Driver License
Social Security
Email Address

I hereby release the Franklin County Sheriff's Office, Franklin County, Ohio, Sheriff Zach Scott, or any of his deputies and/or employees of any and all liability or responsibility for any injury to myself. I release any and all liability and/or responsibility to participate in the Citizens Academy and as a civilian ride along with the Franklin County Sheriff's Office.

MEDICAL HISTORY

Medication taken regularly (names and dosage, etc.):
List any medical problems/physical defects:

List three (3) people to be contacted in case of an emergency:
Name:
Address:
Phone:

Print Name
Date