Ride Along Request Form V2

Ride Along Request Form
This form is designed to collect necessary information from individuals wishing to participate in our Ridealong Program. Please fill out the form completely to ensure we have enough information to process your request. Submitting a request does not guarantee or confirm that you are able to ride the dates requested. You will be contacted by our Ridealong Coordinator to confirm the dates you are scheduled and provide additional information regarding what to wear, who to see when you arrive, and to provide you with the waiver form. Please note that the crews have to be given advanced notice of a ridealong before it can be scheduled, so you must provide dates starting at least 1 week in advance of the date you submit this form. Thank you.
Name*

First NameLast Name
Email*

Confirmation Emailexample@example.com
Preferred Pronouns:*

He/HimShe/HerThey/Them
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
This is required as ride-alongs have age limitations.
Age
Are you currently enrolled in an initial EMT (ALS or BLS) certification program?*
What type of program?*
Where is your program located?*
Instructor / Course Coordinator Name *

First NameLast Name
Are you requesting a ride-along to complete class clinicals or patient contacts?*
Provide the deadline date for your contacts*

MonthDayYear
Date
Please choose the certifications you have from the list below.*

CPREMREMTAEMTIntermediate / ParamedicN/A
LVRS requires CPR for anyone who rides over 12 hours total. If you plan on riding more than 12 hours you will be required to provide your CPR certification.
Please upload a copy of your CPR certification *

Cancelof
Date of Form Submission*

MonthDayYear
Date
Are you affiliated with any other Fire/EMS agencies *
Who are you affiliated with?*
List all available dates and time frames you are available to ride below. Dates must be at least one week in advance to allow time for placement. Shifts are usually 0600-1800 or 1800-0600 but can be adjusted. *
Do you wish to be scheduled for more than one date if possible?*
Are you interested in joining LVRS as a member?*
Special Considerations: Please indicate if you would like to ride with a particular member or crew. Note there is no guarantee we can schedule you with this particular member or crew but it will be taken into consideration.
Should be Empty: