Student Ride Along Application
Bensenville Fire Protection District
Name
*
First Name
Last Name
Email
*
example@example.com
Home Address
*
Street Address
Street Address Line 2
City
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State
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Ride Along Date
-
Month
-
Day
Year
Date
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Informed Consent
I understand that participating in an observation program in the Fire/EMS work environment carries a potential risk of exposure to bloodborne pathogens and airborne/droplet diseases. I have been given the opportunity to ask questions about these diseases and the risks of exposure, and to received answers to my satisfaction. In the event that I am exposed to blood or other potentially infectious materials, I will follow the guidance of the Fire/EMS service and seek medical attention at the location specified in their Exposure Control Plan. I acknowledge that the Fire/EMS service is not responsible for covering the costs associated with any post-exposure medical treatment or counseling.
Student Signature or Parent Signature (if under the age of 18)
*
Student or Parent Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Waiver of Liability
I hereby absolve and hold harmless the Bensenville Fire Protection District #2, the Village of Bensenville, the County of DuPage, the State of Illinois, and any members thereof, whether civil or appointed, from any and all liability for claims that may be made by myself, my family, or my heirs in the event of any injury, personal property loss, damage, or death sustained while riding in, on, or near any apparatus, while training or visiting any fire department installation and its premises, or while attending any emergency scene with the Bensenville Fire Protection District #2.
Student Signature or Parent Signature (if under the age of 18)
*
Student or Parent Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
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