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2. 
4. Rider's Contact Information
6. Full Legal Name*

   First & Last Needed for Background Check

7. Working Email Address*

   *Primary Form of Communication

   The agreement (from Adobe Sign) will be sent to this email as well as the verification letting you know your ride along is officially scheduled. 

9. Birthday*
   Birthday

   Needed for Background Check

10. Phone Number*
12. Address*
14. City*
15. State
16. Zip Code
17. I am a: *
    -- Select One --Civilian / CitizenHigh School Student - Over 18 years oldCollege StudentCFA Alumni - Citizen's Fire AcademyEMS Ride-AlongScout / Explorer ChaplainReserves SMFD ApplicantOther
21. Ride Along Request

    The ride-along program is available on most days of the week, with certain exceptions. Ride-alongs will be from 7:00 am to 7:00 pm. No rider will be permitted to stay overnight at the fire station. We require at least two-weeks notice to ride-out.

23. Requested Date of Ride-Along*
    Requested Date of Ride-Along

    *Date requested must be at least two-weeks out*

24. Start Time*
    Start Time

    7:00 AM Earliest Time Available

25. End Time*
    End Time

    7:00 PM Latest End Time Available

27. Alterative Date *
    Alterative Date
    If the first date isn't available
28. Alternative Date Start Time*
    Alternative Date Start Time

    7:00 AM Earliest Time Available

29. Alternative Date End Time*
    Alternative Date End Time

    7:00 PM Latest End Time Available

31. Is there a SMFD member you know and would like to request to ride out with? If not, you'll check in with Sta 1-114 E Hutchison
33. Please explain the purpose of why you want to ride-along? What are you aiming to gain from riding-along with SMFD? *
37. Initials*
38. Age Requirement
    I acknowledge that I am at least 18 years old & that a background check will be performed before riding out.
40. Initials*
41. 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.
43. Initials*
44. 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.
46. Initials*
47. 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.
49. Initials*
50. Suitable Attire

    Any person approved to ride-along is required to be suitably dressed, to avoid standing out, in a black or dark blue collared (polo) shirt tucked in, dark blue jeans or black or dark blue cargo/ work pants and a pair of black tennis shoes or boots and a black belt.

    Sandals, t-shirts, hats, tank tops, shorts and ripped or torn blue jeans are not permitted. Jewelry and tattoos should comply with the Personal Appearance Standards Policy.

    Members of the Citizens Fire Academy (CFA) are allowed to wear the approved CFA t-shirt instead of a collared (polo) shirt.

    The Operations Assistant Chief or Captain may refuse a ride-along to anyone not properly dressed.

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56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit Submit and Print

* indicates a required field