Ride Along Program Application
Name: ______Date: ______
Date of Birth: ______Valid ID: ______
Address:______
Phone: ______
Date Requested: ______Company Requested: ______
Have you ever been arrested? (Please circle one) Yes No
If yes, list the offense, location, and date of arrest: ______
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EMERGENCY CONTACT(S):
______
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Applicant’s Signature Date
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Chief Officer Approving Application Date
Ride Along Participant Guidelines
1. All participants shall sign the Ride Along Application, Release Statement, and Privacy Statement, and Ride Along Participant Guidelines prior to scheduling their ride time.
2. Clothing requirements include:
a. Black or other dark color, closed toe shoe.
b. Pants shall be neat and conservative in appearance, with no holes or tears in them. Shorts may be worn during the warm months, but shall be neat and of a conservative length. No jean shorts, cut off shorts, or athletic shorts will be permitted.
c. Solid color T-shirt or polo shirt, NO sleeveless shirts or tank tops. In the colder months a solid color sweatshirt or jacket may be worn but should be conservative in appearance.
3. The participant shall present with a neat and conservative appearance; long hair shall be pulled back, minimal jewelry worn with no visible piercing during the riding period, with the exception of stud type earrings.
4. The participation hours shall be between the hours of 0700 and 2200 (7 am to 10 pm) No participant shall be allowed to stay overnight, unless authorized by the Fire Chief.
5. The participant shall act as an observer ONLY while participating in the program.
6. The participant shall be under the authority of the company officer throughout the riding period. Failure to follow the officer’s directions will result in the removal of the privilege to participate in the program.
7. At no time shall a participant be allowed to enter any area deemed Immediately Dangerous to Life and Health (IDLH)
8. The participant shall NOT be permitted to take pictures or use any audio-visual recording device while on scene of an incident.
9. The participant shall follow all safety regulations and department policies on safety (seatbelt use, safety vest, etc)
10. The participant shall not be allowed any weapons while participating in the program.
11. The participant shall report at least 15 minutes prior to scheduled time, so that all safety rules and expectations can be reviewed prior to the start of the ride time.
12. The participant shall be expected to participate in the daily chores of the firehouse (station cleaning, equipment cleaning, etc)
13. Only one participant shall be assigned to a company at one time.
14. Participants shall complete an evaluation of their experience upon completion of their ride time.
I, ______have read and understand the guidelines to participate in Wake Forest Fire Department’s Ride Along program. I further understand that my failure to obey the guidelines shall result in the termination of the privilege to participate in the program in the future.
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Signature of Participant Date
Ride Along Program Liability Release and Indemnity Agreement
I ______, in consideration for being permitted to participate in the Wake Forest Fire Department’s Ride Along program and ride in a vehicle owned and operated by Wake Forest Fire Department, for the purpose of observing the daily operations of the Wake Forest Fire Department, agree to release and hold harmless the Wake Forest Fire Department Inc, its agents, and its employees from and against all claims, costs, and/or damages which may arise as a result from my participation in the Wake Forest Fire Department Ride Along program and related activities.
I further agree to indemnify, defend, and hold harmless the Wake Forest Fire Department, its agents, and its employees any and all sums of money, damages, attorney’s fees, costs, or expenses that may be here after required as a result from any injury or damage which I may cause or receive during my participation in the ride along program and related activities.
I have read and fully understand the foregoing RELEASE and INDEMNITY AGREEMENT.
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Applicant’s Signature Date
Privacy Statement
In 1996 Congress enacted the Health Insurance Portability and Accountability Act (HIPAA) to protect a patient’s right to privacy. Under this act, certain patient information shall remain confidential. This information, known as Protected Health Information (PHI), includes a patient’s name, social security number, insurance information, and/or any other information that is individually identifiable. Other information, such as treatments and patient condition, are also covered under PHI. Any person, who discloses such information without the written permission of the patient, other than when required by law, shall be subject to criminal charges.
The “Golden Rule” of HIPAA can be stated as: What you see and hear here, stays here!
I, ______have read and understand the mandates governed by the Health Insurance Portability and Accountability Act (HIPAA). And, in accordance with this act, I do hereby agree and pledge to keep all protected information pertaining to all patients confidential.
I hereby certify, under penalty of perjury, that I have read and fully understand the privacy statement for observer(s) with the Wake Forest Fire Department.
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Applicant’s Printed Name Applicant’s Signature
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Date
Ride Along Participant Survey
Name of Participant: ______
Date of participation: ______Station: ____ Time: From______to ______
How did you hear of the ride along program? ______
What part of the ride along experience did you find most valuable? Why? ______
What part of the ride along experience did you find least valuable? Why? ______
How might the ride along program be improved? ______
Any additional comments? ______