Ride-Along Observer Program

Please complete all documentation to the best of your ability. Incomplete request forms may not be considered for participation in the Ride-Along Observer Program or Student Ride-Along Program. All fields marked with a red star (*) are required to process your request.

If you would like to complete a physical request form instead, you may print one here. Physical request forms may be delivered to any of our stations, or may be faxed to (937) 587-3602.

If you have any questions, please call (937) 587-3598 or (740) 352-4965.

In consideration of my receiving permission from the Adams County EMS Department to enter upon the premises of any fire station, EMS station or related entity, any Other premises owned and/or operated and/or used by any station within Adams County, and in further consideration of receiving permission from said EMS Department to participate in a Ride-Along Observer Program, wherein I will be riding in, on, or upon EMS Department vehicles or using other apparatus, the undersigned hereby releases the Adams County EMS Department, Adams County Law Enforcement agencies, Adams County Fire Departments and any and all agents, officers, servants, employees, attorneys, or other representatives of the foregoing from any and all liability, claims, demands, actions and causes of actions, whatsoever, arising out of or related to any loss, property damage, physical injury, contagious disease, or death that may be sustained by me while in, on, or upon any premises, vehicles, or apparatus owned, occupied, or used by the foregoing, or which may be sustained by me while at the scene of any real or apparent emergency situation requiring a response of the Adams County EMS Departmentm or while commuting to and from the station(s) and other points.

 

I hereby certify that I am duly aware of the risks and hazards, including serious Physical injury or death, inherent upon participating in the Ride-Along Observer Program, that such risks and hazards may exist even in non emergency situations, and being duly aware of such risks and hazards.

I hereby elect, voluntarily, to participate in the Ride-Along Observer Program.

I hereby assume all risks of loss, damage, and/or injury, including death that may be sustained by me or by any of my property while participating in the Ride-Along Observer Program.

This release shall be binding upon my relatives, spouse, heirs, distributes, next of kin, Executors, administrators, and any other interested parties.

 

In signing this release, I hereby acknowledge and represent:

1. I have read the rules and reguations outlined in General Order, Ride-Along Observer Program.
2. I have read the release, understand it, and sign it voluntarily.
3. I am over eighteen (18) years of age and that I am of sound mind and sound physical health.
4. I am not an agent, servant, or other employee of the Adams County EMS Department.
5. Any injuries or other danage suffered by me will not be compensable by Worker's Compensation or any other insurance program maintained by the Adams County EMS Department.

 

I also agree to the following guidelines:

1. I will abide by any and all applicable rules and regulations of the EMS Department,
2. I will not ride or attempt to ride or use or attempt to use any EMS Department vehicle or apparatus until such time as a duly authorized officer has reviewed with me the procedures for riding or using same.

I also agree that I have no physical handicaps that may affect me during my Participation in this program or which may be aggravated by my participation in this program, except for those which shall be listed in the field below. Further, despise the EMS Department's knowledge of this diability or defect, I agree that their Continuing grant of permission for me to participate in this program shall not subject them to any Liability.

Upon request, a medical waiver statement from a physician could be required. This would help to substantiate fitness to perform in a ride-along observer status on-the-scene of emergency operations.

I also authorize and instruct the Adams County EMS Department or their authorized representatives to notify the following person in case of any accident in which I am involved while participating in this program or while I am commuting to and from the station(s) or other points. This person's information shall be provided in the appropriate fields below.

I have not been denied membership or career status in the Adams County EMS Department for criminal record, background investigation, or medical reasons.

If I have been denied membership in another rescue organization outside of Adams County, said reason(s) will be disclosed to the Adams County EMS Department using the field below.

Should I be a bona fide member of a fire/rescue association or department, I will disclose the name of such organization using the fields below.

By providing my signature below, I hereby certify that the information provided in this form is complete, true and correct to the best of my knowledge.

 

Furthermore, I understand and acknowledge that this form shall become permanent record of the Adams County EMS Department. I also understand and acknowledge that participation in the Ride-Along Observer Program is at the discretion of the administration of the Adams County EMS Department, and that requests may not be fulfilled as submitted, dependent on staffing and availability of the Adams County EMS Department.