Ground Ride Along Application

1. Ride-along participants must be at least 16 years old and currently active in a pre-hospital or emergency/critical care field or a student of these fields above. Those under 18 will need to complete a parental waiver release before scheduling ride-along time.
2. Applications will only be accepted when all materials are received.
3. Participation will be on an ‘observation basis only’ with no involvement with patient care responsibilities. Participants will be under the direct supervision of the lead employee on each call.
4. Participants must keep all patient information confidential! Photo and video recording are prohibited during all runs. Photo and video recording are also prohibited while at referring facilities and/or scenes. Cell phones to be completely off during any call, while in the presence of the patient, and while at a referring facility.
5. Riders will refrain from using social media to discuss their ride-along experience. This includes the use of Facebook, Instagram, Snapchat, Twitter, YouTube, and any other such social networking.
6. Ride-along participants must not have any physical, emotional, or mental condition that may compromise their well-being or the well-being of the patient, crew, or the completion of the mission. Examples of such conditions may include but are not limited to: currently experiencing a communicable sickness or disease; uncontrolled anxiety attacks; uncontrolled claustrophobia, using any controlled substances without a prescription; using any illegal drug or substance. If any of these or similar conditions exist, the participant must discuss these conditions with the ride-along program administrator to determine what reasonable accommodations, if any, may be available to allow participation in the program.
7. Orientation and safety training will be held on the day of the scheduled ride-along prior to any calls.
8. All participants are asked to dress appropriately in EMS uniform or dark cargo style pants, work shoes/boots, and a plain clean shirt (no logos.) Boots must provide ankle support. No low-cut t-shirts. Absolutely no open-toed shoes/sandals, dress shoes with a heel, or tennis shoes will be permitted per safety standards.
9. We recommend bringing reading material or something to work on in the event the crew is involved in patient charting, etc.
10. Participants will be required to pay for their own meals. A microwave and refrigerator will be available should you choose to bring your own food. Breaks will be provided as schedule allows.
11. Please park in the parking lot at the front of the operation building. Upon entering that build the duty supervisor will direct you to the crew.
12. County Rescue is not responsible for lost or stolen articles. Please place personal items in a secure location.
13. In order to accommodate many different agencies, County Rescue may defer
    requests from individuals who live outside of our immediate referral area.

I acknowledge that I HAVE read the County Rescue Ride-Along Guidelines and agree to adhere to the policies and guidelines identified.

I am aware of the inherent dangers of participating in the County Rescue Ride-Along Program (the "Program") including, but not limited to, sudden death or injury as a result of responding to calls.

I am aware of the possibility of exposure to infectious diseases, specifically, but without limitation, those transmitted by blood (such as Hepatitis B and HIV) and air (such as Tuberculosis and Chickenpox) because of my participation in the Program. I am familiar with standard infection control procedures and will have gloves in my possession and will be aware of and know the location of other personal protection equipment that may be required by me to help prevent infection by infectious diseases. I will receive a briefing from County Rescue and I understand the briefing and training given. During my participation in the Program and at all times, I agree to follow prudent procedures to minimize the risk of injury and infection by infectious diseases in accordance with my independent training and instructions by County Rescue staff.

If I am injured in my participation in the Program, I hereby instruct County Rescue to secure and/or provide appropriate medical care to me. 

While I am participating in the Program, I will acquire knowledge concerning the private matters of those with whom I come in contact, including, but not limited to, patients, families, fellow health care professionals, County Rescue, and various other institutions and organizations. This relationship between me and those with whom I come in contact on a professional basis is considered strictly confidential and, therefore, I will not divulge any such private matters to anyone, except to County Rescue and any other medical professional for the appropriate treatment of patients with whom I have come in contact with the Program.

I further agree to the following guidelines, which are not intended to be exhaustive:

1. Regardless of my level of expertise in the medical field, I will remain an observer only and will not provide medical services to any patient during any patient transport during my participation in the Program.
2. I will not discuss with anyone a patient's medical condition or any private matters learned or observed while participating in the Program except as allowed in this Agreement.
3. I will not disclose or release at any time any patient information to the patient, to the patient's family, the media, or any legal professionals or anyone else, except as allowed in this Agreement.
4. I will not view the medical or administrative records of the patient or of County Rescue.
5. I will not remove, video, photograph, or photocopy any medical records pertaining to any patient transported by County Rescue.

I understand that a failure to comply with the above-stated guidelines or other guidelines that may be communicated to me by EAGLE III shall be considered grounds for my immediate dismissal from the Program.

This Agreement is binding on me, my heirs and beneficiaries, personal representatives, successors and assigns, and anyone else claiming under or through me and inures to the benefit of County Rescue, its successors and assigns, insurers and affiliated organizations.

I certify that I have read this Observer Confidentiality and Release Agreement and that I understand its terms. I also acknowledge that it was my responsibility to contact the Ride-Along program director if I had questions about this Agreement or about the Ride-Along program, or about any other documents or agreements provided to me by County Rescue. I acknowledge that if I did contact the program director, that explanations and answers have been provided to my satisfaction.

I understand that County Rescue would not allow me to participate in the Program but for my execution of this Agreement, and I further understand that by executing this Agreement I am giving up certain rights I might otherwise have against County Rescue including my right to file suit for personal injury and the right of my estate to file suit for wrongful death, among other things, and I willingly and knowingly waive those rights in exchange for the opportunity to participate in the Program.

I fully understand and accept the risks involved in the Program and wish to participate in the program because of the personal benefits the Program will provide to me, notwithstanding those risks.

ACCORDINGLY, I HEREBY RELEASE AND HOLD HARMLESS AEGIS GROUP, INC.  AND THEIR RESPECTIVE DIRECTORS, OFFICERS, EMPLOYEES, AGENTS, SUCCESSORS, AND AFFILIATED COMPANIES AND ATTORNEYS OF AND FROM ANY AND ALL DAMAGES, CLAIMS, JUDGMENTS, AWARDS, COSTS, FEES, INCLUDING ATTORNEYS' FEES, AND ANY OTHER CLAIMS OF ANY NATURE WHICH MAY RESULT FROM OR BE RELATED TO MY PARTICIPATION IN THE PROGRAM WHETHER SUCH PARTICIPATION IS RELATED TO IN-FLIGHT ACTIVITY OR OTHERWISE.

I understand that County Rescue provides services to patients that are private and confidential and that I must respect and maintain the privacy rights of County Rescue’s patients. I understand that it is necessary, in the rendering of County Rescue’s services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written, or photographic and that all such information is strictly confidential and protected from improper use and disclosure by federal and state laws.

I agree that I will comply with all confidentiality and security policies and procedures set in place by County Rescue during my experience as a student/guest/trainee with County Rescue. If at any time I knowingly or inadvertently breach the patient confidentiality or security policies and procedures, I agree to notify the Privacy Officer of County Rescue immediately.

I also understand that I may be exposed to other confidential or proprietary information of County Rescue and I agree not to reveal any of that information to anyone at any time.

In addition, I understand that a breach of patient confidentiality will result in the immediate revocation of the privilege to gain clinical experience or observe the activities of County Rescue. Upon termination of this privilege for any reason, or at any time upon request, I agree to return any and all patient confidential information in my possession. I understand that any patient or confidential information that I see, hear, or obtain while a student/guest/trainee will stay here at County Rescue when I leave at the end of my ride-along shift.

I agree to abide by all policies or my privilege to participate in clinical activities or otherwise observe County Rescue activities will be revoked.

For any further questions or information please contact Hilliary Kuchta at:

hkuchta@countyrescue.com