I, your name, have requested that the Lynchburg Police Department allow me to participate in the Citizen Police Academy. I am fully aware of the inherent risks associated with my participation in the Citizen Police Academy which include, but are not limited to bodily injury, physical and emotional disability, death, and property damage. Understanding these risks, it is still my decision to participate in the Citizen Police Academy and in consideration of the Police Department allowing me to participate, I assume full responsibility for such risks. I agree that neither I nor my legal representatives, heirs, and assigns, will hold the City, its officials, or agents, responsible for any injuries, disabilities, physical and mental diseases, death, property damage, or losses and expenses of any nature whatsoever that I may sustain as a result of my participation in the Citizen's Police Academy, whether caused by the negligence of the City, its officers, employees and agents, or otherwise.

I further agree to indemnify, hold harmless, and to assume the defense of the City, its officers, employees and agents, from all claims and expenses of any nature whatsoever, including the cost of defending such claims which may accrue against, be charged to, or recovered from or sought to be recovered from the City, its officials, employees and agents, as a result of my participation in the Citizen Police Academy.

I understand that this agreement is intended to be as broad and inclusive as permitted by the laws of the Commonwealth of Virginia, and that if any portion thereof is held invalid, it is agreed that the balance shall, not withstanding, continue in full force and effect.

I further understand that permission to participate in the Citizen Police Academy is granted subject to the rules and regulations of the Police Department and such permission may be restricted or revoked entirely by the Police
Department in its sole discretion.