Ridealong Request
This form is designed to collect necessary information from individuals wishing to participate in our Ridealong Program.  Please fill out the form completely to ensure we have enough information to process your request.  Submitting a request does not guarantee or confirm that you are able to ride the dates requested.  You will be contacted by our Ridealong Coordinator to confirm the dates you are scheduled and provide additional information regarding what to wear, who to see when you arrive, and to provide you with the waiver form.  Please note that the crews have to be given advanced notice of a ridealong before it can be scheduled, so you must provide dates starting at least 1 week in advance of the date you submit this form.  Thank you.  
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Email *
First and Last name *
Phone Number *
Are you over the age of 18 (Yes or No)? If NOT, how old are you? *
Are you currently enrolled in an EMS class? *
Do you currently have a valid CPR certification or any EMS Certifications? If so please list them below. If not, write N/A. *
Are you requesting a ridealong for EMT or ALS class clinicals/patient contacts?   *
If you are requesting a ridealong for EMT class contacts OR ALS clinical opportunities, please provide your program location (i.e. John Smith's EMT class, VCU, JSRCC, JTCC, etc), primary instructor's name, & date of expected completion. If ALS, are you in the skills only phase or are you in the ALS team leads phase. If not in an EMT/ALS class, put N/A below. *
Are you interested in joining LVRS as a member? *
Which shift are you able to ride? Day shift is 6am-6pm and Night shift is 6pm-6am. *
Are you affiliated with any other EMS or Fire agencies and if so, which ones?   *
Please provide SEVERAL dates that you are available to ride and the timeframes you are available each date.  I.e. 4/15/19 from 8a-6p; 4/21/19 from 3p-11p. As a reminder, please give availability starting at least 1 week in advance of the date this form is submitted.   *
Do you wish to be scheduled for more than one date if possible?   *
Special Considerations: Please indicate if you would like to ride with a particular member or crew.  Please note that there is no guarantee that you will be able to ride with a specific member/crew, but this will be taken into consideration when scheduling your ridealong(s).
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