Student Ride-Along Program

Student Ride-Along Program
Please complete all documentation to the best of your ability. Incomplete request forms may not be considered for participation in the Ride-Along Observer Program or Student Ride-Along Program. All fields marked with a red star (*) are required to process your request.

If you would like to complete a physical request form instead, you may print one here. Physical request forms may be delivered to any of our stations, or may be faxed to (937) 587-3602.

If you have any questions, please call (937) 587-3598 or (740) 352-4965.

Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Ride Along Period Beginning Date*

MonthDayYear
Ride Along Period Ending Date*

MonthDayYear
Note: at the end of the given time period, a new form must be completed. This time period is also subject to change at administration discretion.
Station Desired*
Note: this is not a guarantee of placement at a station, and is subject to availability and staffing

Emergency Contact
I also authorize and instruct the Adams County EMS Department or their authorized representatives to notify the following person in case of any accident in which I am involved while participating in this program or while I am commuting to and from the station(s) or other points. This person's information shall be provided in the appropriate fields below.
Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.

Signature and Submission
By providing my signature below, I hereby certify that the information provided in this form is complete, true and correct to the best of my knowledge. Furthermore, I understand and acknowledge that this form shall become permanent record of the Adams County EMS Department. I also understand and acknowledge that participation in the Student Ride-Along Program is at the discretion of the administration of the Adams County EMS Department, and that requests may not be fulfilled as submitted, dependent on staffing and availability of the Adams County EMS Department.
Signature*

Clear
Should be Empty:

Emergency Contact