Application for BVRS Ride Along Program
Blacksburg Volunteer Rescue Squad provides an opportunity for community members and students to participate in a ride-along program to gain a better understanding about working in the emergency medical environment. For more information, visit www.blacksburgrescue.org
What is your full legal name? *
As shown on your Driver's License or Government ID
Your answer
Do you have a preferred nickname?
How would you like for use to address you?
Your answer
Please specify gender. *
This is required for background investigation.
First Choice: What date and time would you like to START your ride-along? *
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Time
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First Choice: How long would you like for your ride-along to last? *
We typically schedule in two-hour increments.
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Second Choice: What date and time would you like to START your ride-along? *
MM
/
DD
/
YYYY
Time
:
Second Choice: How long would you like for your ride-along to last? *
We typically schedule in two-hour increments.
Hrs
:
Min
:
Sec
Third Choice: What date and time would like to START your ride-along? *
MM
/
DD
/
YYYY
Time
:
Third Choice: How long would like for your ride-along to last? *
We typically schedule in two-hour increments.
Hrs
:
Min
:
Sec
Realizing the dangers inherent in rescue work, I waive any clain against the Town of Blacksburg or its employees, Blacksburg Volunteer Rescue Squad or its officers or members, the County of Montgomery or its employees of liability for any injury or property damage that might arise through my participation. *
Required
I expressly acknowledge that there is a risk of injury or death in participating in the program. I will be traveling in an emergency vehicle at potentially high speeds. In addition, I may be traveling to places of danger, where there may be a risk of explosion, exposure to hazardous materials, fire, passing vehicles, physical violence, exposure to blood and blood-borne diseases (including AIDS and hepatitis) or other circumstances that may result in injury or death to myself. I choose to participate in the program fully aware of these risks. *
Required
I fully understand that I am NOT to exit the vehicle I am riding in to accompany the member(s) unless told to do so by a member or exigent circumstances dictate that I leave the vehicle *
Required
I affirm that I have never been convicted of a felony involving any sexual crime. I further affirm that I have not been convicted of any other felony under the laws of this State or of the United States within the last five (5) years. I understand that by signing this form, I authorize Blacksburg Volunteer Rescue Squad to obtain my Criminal or any other Background information. *
Required
ATTIRE: Casual dress pants and conservative blouse/collared shirt should be worn. No shorts are allowed; shoes must be worn. *
Required
By typing your full legal name in this field, you agree to the terms and conditions of the Ride-Along Program.
Type your full name below
Your answer
What is your date of birth? *
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What is your address? *
If you are a student, please enter your local address and permanent address.
Your answer
What is your phone number? *
We may need to contact you by phone to follow up regarding this application.
Your answer
What is your email address? *
Your answer
What is your preferred method of contact? *
Please enter an emergency contact name. *
Your answer
Please enter a reliable phone number for your emergency contact. *
Your answer
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