Ride Along Application

SOUTH LAKE COUNTY FIRE PROTECTION DISTRICT

APPLICATION – RIDE‐ALONG PROGRAM
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
D/L’S #*
Address*
Street Address, City
Phone Number*
Please enter a valid phone number.
Is the Ride Along Applicant a student*

YesNo
Occupation*
In case of emergency, notify (Name)*
(Phone Number)*
Have you ever participated in a Ride Along Program with this District before?*

YesNo
Date you participated*

MonthDayYear
Date
Reason for Ride‐Along*
AGREEMENT ASSUMING RISK OF INJURY OR DAMAGE AND INDEMNIFY

Whereas the undersigned being (under) (over) the age of twenty one, and not being a member, employee or agent of South Lake County Fire Protection District, has made a voluntary written Request for permission to ride as a member of the South Lake County Fire Protection District, and Has further requested permission to accompany a member of said District during the active performance of his/her official duties.

Now, therefore, in consideration of the granting of the foregoing permission to ride with and accompany District personnel of the South Lake County Fire Protection District, the undersigned Does hereby waive, release, discharge and hold harmless theSouth Lake County Fire Protection District and its officers, employees and agents from any and all claims, actions, or causes of action, for damages, death, personal injury or property damage, which may have, or which may hereafter accrue to me asa result of riding with or accompanying South Lake County Fire Protection District personnel while in the performance of their duties.

I further understand that serious accidents occasionally occur during emergency responses and that the persons riding in South Lake County Fire Protection District equipment occasionally sustain serious personal injuries. Knowing the risk of the Ride-Along Program, nevertheless, I hereby agree to assume those risks and to release and hold harmless all of the personnel and entities mentioned above who might otherwise be liable to me (or my heirs or assigns) for damages.

It is further understood and agreed that this waiver, release, and assumption of risk is to be binding on my heirs and assigns.

READ THIS DOCUMENT COMPLETELY BEFORE SIGNING
Signature*

Clear
Date*

MonthDayYear
Date
Is applicant under 18 years of age*

YesNo
Parent/Guardian Name:
Parent/Guardian Signature:

Clear
Should be Empty:

SOUTH LAKE COUNTY FIRE PROTECTION DISTRICT