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2. 
4. Rider's Contact Information
6. Full Legal Name*
   First & Last Needed for Background Check
7. Email Address*
   *Primary Form of Communication
9. Address
11. City
12. State
13. Zip Code
15. Phone Number*
16. Birthday*
    Birthday
    Needed for Background Check
17. I am a:*
    -- Select One --Civilian / Citizen High SchoolCFA Member-Citizen's Fire AcademyCollege StudentExplorer / ScoutChaplainReservesSMFD 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 10:00 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
    10:00 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
29. Alternative Date End Time*
    Alternative Date End Time
31. Is there a SMFD member, shift, or station you'd like to request to ride out with?
32. Care to explain the purpose of why you want to ride-along? What are you aiming to gain from riding-along with SMFD?
34. Initials*
35. Age Requirement
    I acknowledge that I am at least 18 years old & that a background check will be performed before riding out.
37. Initials*
38. 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.
40. Initials*
41. 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.
43. Initials*
44. 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.
46. Initials*
47. Suitable Attire
    Any person approved to ride-along is required to be suitably dressed in a collared shirt, blouse or jacket, slacks and shoes. Sandals, t-shirts, tank tops, shorts and ripped or torn blue jeans are not permitted. Hats and ball caps will not be worn in the fire apparatus. Jewelry and tattoos should comply with the Personal Appearance Standards Policy. The Operations Assistant Chief or Captain may refuse a ride-along to anyone not properly dressed. Members of the Citizens Fire Academy (CFA) are allowed to wear the approved CFA t-shirt.
53. 
55. Date Requested to Ride-Along
    Date Requested to Ride-Along Start Date

    Date Requested to Ride-Along Start Time

    —

    Date Requested to Ride-Along End Date

    Date Requested to Ride-Along End Time
56. SHIFT

    1. A-SHIFT
    2. B-SHIFT
    3. C-SHIFT
57. Background Check Completed
    Background Check Completed
59. Shift BC Approved by:
60. Shift BC Approved Date:
    Shift BC Approved Date:
61. Ops Chief Approved Date
    Ops Chief Approved Date
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit Submit and Print

* indicates a required field