Ride-Along Application
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Back
Next
Personal Information
Date of Birth
*
-
Month
-
Day
Year
Date
Are you over the age of 18 as of the date of this application?
*
Yes
No
Back
Next
Minor Release Information
Parent or Legal Guardian Name
*
First Name
Last Name
Parent or Legal Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent or Legal Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent of Legal Guardian Email Address
*
example@example.com
Back
Next
Emergency Contact Information
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to you?
*
Please Select
Mother
Father
Step-Mother
Step-Father
Legal Guardian
Spouse
Brother
Sister
Cousin
Other
Back
Next
Acknowledgements
Dress Code - You are expected to dress in a navy polo/T-shirt, long, navy blue pants, and closed toed black shoes/boots. However, you may dress in a gray or white polo, long khaki/black/brown pants, and closed toed brown/black shoes or boots. Think Professional! If you are an EMT student, please wear your provided EMT shirt and provide a letter from you instructor stating you are in class and the skills you may provide. If you are a member of another agency and are doing a ride along to fulfill ride time for your volunteer agency or for employment, please have one of your officers sign and the skills you can do/need. You are NOT allowed to wear any clothing with sizeable logos on it or shoes with bright colors, sandals, flip flops, or any kind of open-toed shoes. Please do not wear clothing with other fire or EMS logos on it unless this ride along program is to fulfill requirements at that agency. You are NOT allowed to wear jeans, shorts, or sweat pants. For females, you also are NOT allowed to wear dresses, skirts, or tights/leggings. Avoid wearing perfume/cologne as patients may be allergic to them. Avoid wearing clothes that are too tight. You should be able to have a range of motion as EMTs may have to be able to bend their knees, kneel on the ground, and etc. for a prolonged period of time.
*
Agree
No alcohol or drug consumption for the last 12 hours prior to the scheduled ridealong.This includes prescription drugs that may cause drowsiness or impair theability to drive or operate machinery.While on a call, you are expected to act appropriately (NO horse-playing, NO fowllanguage). You may be asked to assist the attendant-in-charge (AIC) and thedriver. If you are not comfortable doing something when asked, do not be afraid toverbalize it. Please refrain from asking questions about a call until the call hasended. Please do not talk about irrelevant topics in the presence of the patient andfamily. In addition, do not answer questions from patients or family members or bystanders; refer them to the AIC or driver and do NOT interfere with patient care.You are expected to maintain patient confidentiality as defined by HIPAA. You can NOT go out into the public and talk about the things you see or hear during patient care.You are expected to wear a seat belt at all times when the ambulance is in motion unless directed otherwise by the AIC and do not wander off/away from your crew members. They are responsible for your well-being and it adds unnecessary stress to the situation they have to deal with or manage.We allow those 16 years of age and older to participate in the ride long program.If you are not 18 years of age, a parent or guardian will need to arrive with you at the start of shift for consent to do a ride-along and to sign the agreement along with the person doing the ride-along.The senior medic or any officer has the right to send you home if deemed necessary for any reason. They also retain the right to deny you the opportunity toride-along as they deem fit, without prior notice.
*
Agree
Federal law prohibits the unauthorized sharing of patient information. Patientinformation such as their name, demographic data, medical condition, or any otheridentifying information is strictly confidential and is NOT to be disclosed, in anyform, to anyone except ambulance personnel and others who are authorized underHIPAA to receive such information. Riders are encouraged to treat ALL patient information as confidential and to consult the ambulance crew with any questions regarding HIPAA laws. Please carefully read and agree to the following statement:I will treat all patient identifiable information as strictly confidential. This information includes, but is not limited to, the patient'sname, address, telephone number, date of birth, age, social security number,medical condition, treatment received, and past medical history. I will not share, in any form, patient identifiable information with friends, family, or others who are not directly involved with patient care. If, at any time during or after the ridealong,I am asked a question about a patient, I will refer the asking person to theambulance crew or fire department officers. I understand that if I disclose patientidentifiable information, even unintentionally, I may be subject to civil and/orcriminal penalties.
*
Agree
By signing below you agree to all statements listed above and certify that all information provided on this form is true and accurate to the best of your ability.
*
Parent or Legal Guardian Signature (if applicant is under 18 years of age)
Continue
Continue
Should be Empty: