Person desiring to ride must sign the following waiver, prior to riding. Persons under the age of 18 must have form co-signed by his or her parent or legal guardian.

By signing this waiver, I hereby now and forever, release the Burtonsville Volunteer Fire Department, Inc.; all of its members, administrative and line officers, including the Chief and President, and the Montgomery County Government; from any liability for injury or death that might result from any activities associated with my riding on emergency apparatus. I further agree to adhere to the rules of the BVFD and Montgomery County Fire Rescue and to follow all lawful instructions given to me. I hereby certify that all of the above information is true and that I am signing this form after having read and understanding it, in its entirety.

I authorize a criminal record check be completed in compliance with the guidelines of this program. I understand that the full name, sex, and date of birth information recorded on this form is required to check my criminal record.

Montgomery County Government
(Fire and Rescue Service)
Release and Indemnification Agreement

The Ride-Along (Observer) Program of the MCFRS is understood by me as one inherently dangerous and one in which I may well be exposed to substantial danger at any or all times of my participation or preparation for participation in said program and that I am assuming all risks thereby.

I expressly acknowledge having read this Contract and understand all it terms. I further acknowledge that I have executed it voluntarily for consideration and with full complete knowledge of its signature. I further agree to indemnify the Montgomery County Government, the Montgomery County Fire and Rescue Service, its agents, and employees and others listed above for all costs, counsel fees, judgments, settlements, other expenses in the event that any claim or result of damage or injury to any person (including myself) or property arising out of my participation in any manner in the Ride-Along Program. I agree to forthwith obey all instructions and to
abide by all rules and regulations of the MCFRS and Fire Rescue Commission, in general.

IN WITNESS WHEREOF, I execute this Contract, the day and year first written, in Montgomery County, Maryland with full knowledge of its terms, and content. I further acknowledge that this Release and Indemnification Agreement is the complete and total understanding of the parties and that it has not been nor may it be modified, amended, changed or withdrawn by an oral understanding by any person, under any
circumstance.

Your Duty to Protect Client Information under HIPAA and other Privacy Laws

Why do we need to protect health and other personal information about the people served by Montgomery County Fire and Rescue Service (MCFRS)?

The County is committed to protecting the privacy of the people it serves, and these people have a legal right to expect privacy in the way their personal information is used. The Health Insurance Portability and Accountability Act (HIPAA) and the Maryland Confidentiality of Medical Records Act protect the confidentiality of health information for people served by the County’s Fire and Rescue Services.

How does this apply to me?

While participants are riding along with Montgomery County Fire and Rescue Service, they are obligated to comply with the same HIPAA requirements as our personnel. This means:

Participants may not disclose any information they have seen, heard or observed during their ride along. This includes, but is not limited to, disclosing information to family and friends.

Ride along participants must not photograph or record, any individuals while participating in the ride along.

What information is confidential? All identifying information about the people served by MCFRS is confidential, regardless of whether it is heard, seen, written or electronic. For example, a patient’s name, address, medical condition, medication usage, or even just the fact that they were served by Fire and Rescue Services, must be treated as confidential information and not shared with anyone. Photographic images and recordings are also identifying confidential information.

What happens if I disclose confidential information?

If you violate privacy and confidentiality laws, you may put the County and yourself at risk for fines, penalties and lawsuits. In certain circumstances, there can be criminal penalties, including incarceration.

My obligation:
By participating in this ride along, I understand I am obligated to comply with all laws and regulations that protect the privacy of health and other personal information.

My obligation under HIPAA has been explained to me by MCFRS personnel.

I agree to comply with all laws and regulations that protect the health and other personally identifiable information about people being served by MCFRS.