2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
13. Preferred Ride Along Date *
    Preferred Ride Along Date

    Please note: Unless enrolled in an approved medic program, a ride along may only be scheduled on Monday - Friday's and will begin at 0800 and end at 1700. 

15. Upload the completed Ride-Along Application Packet here: *

    Upload the Ride-Along Application Packet, Ride-Along Rules of Conduct, the Ride-Along Liability Release Form and the completed background check here. Please double check that your forms are legible and complete prior to submission. 

17. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
19. Electronic Signature
Leave This Blank:


21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit

* indicates a required field