County Rescue Ground Ride Along Application

Ground Ride Along Application

Fill out the form carefully for registration
Due to COVID, ride along requests will be limited to health-care providers and students pursuing employment in EMS.
Full Name *

First Name Last Name
Birth Date *

Month Day Year
Age *
Age
Gender *
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Main Phone Number *

Area Code Phone Number
Preferred Methods of Contact *
Driver's License Number *
Driver's License State *
Height *
Weight *
Hair Color *
Eye Color *
Employer or School *
Reason for Ride-Along *
Have you ever ridden along before? *
If yes, when?
Physical disabilities or required accomodations *
Are you under the care of a physician or experiencing a disease that may be communicable? *
Are you pregnant? *
Have you ever been convicted of any misdemeanor offenses? *
If yes, explain the offence, when it occurred and sentence:
Have you ever been convicted of any felony offenses? *
If yes, explain the offence, when it occurred and sentence:
Do you currently have charges pending? *
If yes, explain:
1st Choice Date *

Month Day Year
Hours Requested *
Our normal ride along hours are 0900-1800
2nd Choice Date *

Month Day Year
Hours Requested *
Our normal ride along hours are 0900-1800
3rd Choice Date *

Month Day Year
Hours Requested *
Our normal ride along hours are 0900-1800
Additional Comments
For any further questions or information please contact Hilliary Kuchta at:

hkuchta@countyrescue.com
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