Berkeley County Emergency Ambulance Authority Ride-Along Form

Berkeley County Emergency Ambulance Authority Ride-Along Form

Applicants must be at least 16 years of age at the time of the ride-along. Applicants under 18 years of age MUST provide parent/legal guardian contact information.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Parent/Legal Guardian

First NameLast Name
Parent/Legal Guardian Phone Number
Please enter a valid phone number.
Parent/Legal Guardian Email
example@example.com
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Ride-Along Dates

Applicants Can Select Up to Three Ride-Along Dates
Requested Ride-Along Date*

MonthDayYear
Date
Requested Ride-Along Date

MonthDayYear
Date
Requested Ride-Along Date

MonthDayYear
Date

BCEAA RIDE-ALONG GUIDELINES

There are inherent risks involved in participating in a ride-along and all riders are required to fully read, understand, and agree to the instructions and waivers. With the appropriate safeguards, non-EMS personnel can ride safely and gain a good perspective on EMS operations and the types of services BCEAA provides.
Dress Code

Pants/Jeans: Riders must wear dark navy blue or black pants or jeans (no leggings). Shorts are not permitted to ensure protection and professionalism.

Shoes: Black shoes or boots are preferred but not required. Must be closed toe for safety. Avoid high heels or shoes that might impede mobility or safety.

Shirts: A solid color (preferably dark or navy blue) t-shirt or polo is required. Shirts should be neat, clean, and without tears or frayed edges.

Branding and Logos: Shirts must not have any advertising, slogans, or logos from commercial products, businesses, or outside Fire/EMS agencies. This helps maintain a neutral and professional appearance.

Outerwear: In case of cold weather, a plain, dark-colored jacket or coat is advisable. Avoid brightly colored or heavily branded outerwear.

General Appearance and Hygiene

Cleanliness: Participants must arrive clean and maintain a level of personal hygiene that is not offensive to patients, staff, or coworkers throughout the duration of the ride-along.

Hair: Must be neat, clean, and of a naturally occurring color.

Facial Hair: If present, facial hair must be uniform in length and naturally colored.

Tattoos and Piercings

Tattoos: Tattoos that could be considered vulgar, offensive, or unprofessional must be covered at all times during the ride-along. If there's any doubt about a particular tattoo, it should be covered as a precaution.
Piercings: Only stud-style earings are permitted. Hoop earrings or large, dangling earrings are not allowed for safety reasons.

Personal Equipment

Identification: Riders should carry government-issued photo ID at all times.

Personal Protective Equipment (PPE): Riders will be provided with the necessary PPE, such as gloves and masks. Instructions on when and how to use these will be given.

Prohibited Items: Riders should not bring weapons or recording devices. Personal belongings should be kept to a minimum for safety and convenience.

Conduct/Safety:

Health and Safety: Riders should bring their own water bottle and any necessary medications. They are encouraged to inform EMS personnel of any health issues that may affect their ride-along experience.
- You must follow ALL directions given to you by BCEAA EMS personnel.
- You must wear all necessary personal protective equipment.
- You must at all times, be in the immediate vicinity of the ambulance crew unless directed otherwise by BCEAA personnel. If you must leave the station, ambulance, or crew for any reason, you must notify your assigned personnel.
- You must wear a seatbelt at all times when riding in a vehicle.
- You may assist with patient care only when directed by your assigned EMS personnel.
- You are expected to behave professionally and courteously to all patients, bystanders, crew members, and other agency personnel.
- You must immediately report any injury, illness, or other problem to your assigned EMS personnel.
- AT NO TIME will you photograph or record any person, vehicle, or scene.
Adherence to Guidelines: Failure to adhere to these guidelines will result in the cancellation or rescheduling of the ride-along.
I *, have read the above Berkeley County Emergency Ambulance Authority ride-along guidelines and I agree to abide by them. I understand that a violation of any of the above policies is grounds for the immediate termination of my ride-along. I also consent to the use of my photograph and name by BCEAA to publicize and make reports about this ride-along program.
Name*

First NameLast Name
Signature of Ride-Along (Parent/Legal Guarding if Under 18)*

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Confidentiality (HIPAA) Guidelines
As a participant in the ride-along program of Berkeley County Emergency Ambulance Authority (BCEAA), I * acknowledge and understand the following confidentiality requirements as they pertain to patient information and the Health Insurance Portability and Accountability Act (HIPAA):
1. Confidentiality of Patient Information:
  - I understand that during my ride-along, I may have access to confidential patient information, both verbal and written.
  - I agree not to disclose any patient information to anyone, except as directed by EMS personnel in the course of their duties.
2. Understanding of HIPAA:
  - I recognize that HIPAA is a federal law that protects the privacy of individuals’ medical records and other personal health information.
  - I am aware that it is illegal to use or disclose any patient health information for any purpose other than treatment, payment, or health care operations, as defined by HIPAA, without the express consent of the patient.
3. Use of Information:
  - I will only use patient information for the purpose of my ride-along experience and learning.
  - I understand that all information about patients, including their identity, medical condition, treatments, and any conversations overheard, is confidential.
4. Social Media and Communications:
  - I agree not to post any information related to patient encounters, including photos or general descriptions, on social media or other communication platforms.
  - I will not discuss any specific patient information with friends, family, or others not directly involved in the patient’s care.
5. Reporting Violations:
  - I will immediately report any breaches of confidentiality or HIPAA violations that I become aware of to the EMS personnel in charge or the designated HIPAA officer at the BCEAA.
6. Consequences of Violation:
  - I understand that violation of these confidentiality guidelines or HIPAA regulations may result in immediate termination of my ride-along experience and potential legal action against me.
7. Acknowledgment of Understanding:
  - I have read and fully understand these confidentiality guidelines.
I agree to abide by these guidelines and uphold the highest standards of privacy and confidentiality regarding patient information.
Name*

First NameLast Name
Signature of Ride-Along (Parent/Legal Guarding if Under 18)*

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Ride-Along Waiver and Release of Liability
I hereby acknowledge my participation in the ride-along program with Berkeley County Emergency Ambulance Authority (BCEAA) and understand that such participation can involve certain risks. These risks include, but are not limited to, potential injury, trauma, or stress due to the nature of emergency medical services.
1. Assumption of Risk:
  - I recognize that participation in the ride-along program may expose me to a certain level of risk, including physical injury or psychological stress.
  - I voluntarily assume all risks, both known and unknown, associated with my participation in the ride-along program.
2. Release of Liability:
  - I hereby release, waive, and discharge BCEAA, its officers, agents, employees, and volunteers from any and all liability, claims, demands, actions, and causes of action whatsoever directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me while participating in the ride-along program or while in, on, or around EMS premises where the program is conducted.
3. Indemnification:
  - I agree to indemnify and hold harmless BCEAA from any loss, liability, damage, or costs, including court costs and attorneys’ fees, that they may incur due to my participation in the ride-along program, whether caused by the negligence of the agency or otherwise.
4. Medical Treatment:
  - I consent to receive medical treatment deemed necessary if I get injured or require medical attention during my participation in the ride-along. I agree to be financially responsible for any medical bills incurred as a result of medical treatment.
5. Acknowledgment of Understanding:
  - I have read this waiver of liability and fully understand its terms. I acknowledge that I am signing this waiver freely and voluntarily, and intend by my signature to provide a complete and unconditional release of all liability to the greatest extent allowed by law.
6. Duration of Agreement:
This agreement shall remain in effect for the duration of my participation in the ride-along program.
Name*

First NameLast Name
Signature of Ride-Along (Parent/Legal Guarding if Under 18)*

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Berkeley County Emergency Ambulance Authority Ride-Along Form

Ride-Along Dates

BCEAA RIDE-ALONG GUIDELINES

Confidentiality (HIPAA) Guidelines

Ride-Along Waiver and Release of Liability