SAMPLE

RIDE-A-LONG PROGRAM

        The purpose of this guideline is to establish a procedure to be followed for non-members who wish to ride along in ________________ vehicles. This will allow persons interested in employment/membership as well as persons wishing to study Emergency Services for journalistic or scholastic reasons an opportunity for first hand experience.

        The following guidelines shall be followed regarding participation in the Ride Along Program:

THE PARTICIPANT WILL READ, CHECK AND PLACE THEIR INITIALS NEXT TO EACH BOX IF THEY ARE IN AGREEMENT WITH THESE CONDITIONS! (All boxes must be checked prior to permission being granted)

☐  Persons wishing to ride long must be at least 18 years of age (unless they can provide a         permission slip from a parent or legal guardian.)

☐  Requests for participation shall be directed to ________________.

☐  Participants must sign assumption of risk and liability release form;

☐  Participants shall only ride along with crew members; ______________________ shall be

       notified and may decline the ride along at his or her discretion;

☐  Participants shall not wear any type of clothing which would indicate employment/membership         with ________________________; they shall dress appropriately and  no shorts, open toed         shoes, or clothing from other organizations shall be worn;

☐  Participants shall not become involved in emergency activities or patient care and must remain

       outside incident scene lines.

☐  Participants shall wear a seatbelt while in a moving vehicle.

☐  Participants are not permitted to operate vehicles or equipment.

☐  __________________________________ is responsible for the safety and conduct of a

      participant and may cancel the ride along session at his or her discretion;

☐  ______________________________________________ will document a ride along on the Run         Log and Run Form and the word “Observer” with the participant’s initials will be listed on each         run form in lieu of member name or number.

RIDE ALONG PROGRAM

ASSUMPTION OF RISK AND LIABILITY RELEASE FORM

GENERAL RELEASE

• I, ___________________, of _______________________________, do hereby acknowledge that I have in the ________day of _________________, 20___, requested to ride in a vehicle owned and controlled by  _________________________________ members or employees in the performance of their official duties for the purpose of ___________________________.

• I further acknowledge that I have been advised of the dangerous nature of the work and am fully aware of the inherent dangers of riding in an emergency vehicle.

• Now, therefore, in consideration for my being permitted to ride ________________________________ Vehicles, I voluntarily and knowingly assume the risk for any injuries that I may sustain during the pursuit if my activities while riding in vehicles or while on any of the properties owned or controlled by ____________________.  I further, with the intention of binding myself, my spouse, my heirs, legal representatives and assigns, o hereby voluntarily and knowingly remise, release, and forever discharge and hold harmless _____________________, it’s officers, members and employees from actions, suits, damages, claims, or judgments that may result from my personal injury which I sustain while riding on any ________________ vehicle or while upon any of the properties owned or controlled by.

• I have read and fully understand the provisions of this release and have voluntarily and knowingly execute said release with the express intention of effecting the extinguishment of claims and liability herein designated. I also understand that it is my responsibility to thoroughly and completely follow instructions given to me by representatives of _________________________ and my riding privileges may be terminated at nay time for breach of these instructions.

• I understand that certain confidential information including personal medical information may be obtained during my ride along and that that information may not be disclosed to anyone for any reason.

• The provisions of this release shall prevail until revoked in writing to me, but in no event shall these provisions extend beyond 12:01 a.m. on the _______ day of__________, 20___.

• In testimony whereof, witness my hand on this _______ day of _______________, 20___.

____________________________                _________________________________

Releaser                                                 Witness