Ride-Out Request Form

Please complete all information below. Fields with a * are required.

Name Name First Last
Email
Birth Date Birth Date / MM / DD YYYY
Address Address
Street Address City State / Province / Region Postal / Zip Code
Phone Phone - ### - ### ####
Requested date for ride along Requested date for ride along / MM / DD YYYY
Requested time for ride along Requested time for ride along : HH MM AM/PM
Requested Duration in hours
Must be a number less than or equal to 12.
Enter the requested duration of ride along
Is there a specific member of the department you would like to ride along with? If so, enter their name below.
What is the purpose of your ride-along?
Maximum of 250 characters allowed. Currently Entered: 0 characters.
Ride-along requirements and specific policies

This is the description of your section break.
Check each box to indicate you have read and agree to each statement.

Check each box to indicate you have read and agree to each statement. Age Requirement - I acknowledge that I am at least 18 years old & that a background check will be performed before riding out. Patient Confidentiality - Prior to participating in a ride-along, every participant who may come into contact with private health-related information will be required to complete Health Insurance Portability and Accountability Act (HIPAA) training and sign a nondisclosure agreement to keep all confidential information learned during the ride-along confidential. Good Health Clause - The participant must be in good health and must not be suffering from any illness or injury, including cold, flu or respiratory infection, on the day of the ride-along. Waiver or Claims and Release of Liability - Prior to participating in a ride-along, every person must acknowledge the risks and sign a written waiver of claims and release of liability. Suitable Attire - Any person approved to ride-along is required to be suitably dressed in dark pants or jeans, a plain t-shirt or polo shirt, tennis shoes or boots, and appropriate weather attire (coat, wind breaker, etc.) Sandals, t-shirts, hats, tank tops, shorts and ripped or torn blue jeans are not permitted. Jewelry and tattoos should comply with departmental policy. A Lieutenant or above may refuse a ride-along to anyone who does not adhere to any of these policies or if the ride along participant fails to follow instructions of the officer in charge during the ride along.
Liability Waiver and PHI Confidentiality Form
Print, sign, and bring with you to your ride along. You will not be permitted to participate in any ride along activities until the signed form is on file.
By signing below, I affirm that I have read and agree to the above stipulations. I also have read and agree to the Waiver of Liability and Confidentiality of PHI policy.
I understand this is a legal representation of my signature.

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Ride-Out Request Form

Ride-Out Request Form

Ride-along requirements and specific policies

Liability Waiver and PHI Confidentiality Form Print, sign, and bring with you to your ride along. You will not be permitted to participate in any ride along activities until the signed form is on file.

Liability Waiver and PHI Confidentiality Form
Print, sign, and bring with you to your ride along. You will not be permitted to participate in any ride along activities until the signed form is on file.