Student / Ride-Along Application — Central Campbell County Fire District

Applicant

First name *

Middle

Last name *

Date of birth *

Cell phone *

Home phone

Email *

Street address

City

State

ZIP

Parent / Guardian

Because the applicant is under 18, a parent or legal guardian must provide their name and consent.

Parent / guardian full name *

As the parent/guardian, I consent to this minor participating in the Central Campbell County Fire District ride-along program and agree to the acknowledgments below on their behalf. *

Program

Are you an EMS student?

Yes No

School / program name

Program type

Expected graduation (if a student)

Ride Type

Which type of ride-along is this? *

Observer / Ride-Along (SOG 1023.10 / 4.20) Student — Clinical Field Time (SOG 1023.11)

Observer = casual ride-along (SOG 1023.10 EMS / 4.20 Fire). Student = clinical field time with a CCCFD preceptor (SOG 1023.11). If you're a student earning EMS clinical hours through Gateway / Cincinnati State / etc., pick Student.

Student Clinical Details · SOG 1023.11

Educational program *

Only programs CCCFD has a current clinical agreement with. If yours isn't listed, contact the EMS Coordinator before applying.

Your current certification level *

EMT AEMT Paramedic

Your preceptor will be assigned at or above this level (SOG 1023.11).

Shift start *

Earliest: 07:30

Shift end *

Latest: 22:30

Are you a current CCCFD employee?

Yes, I'm a CCCFD employee

Ride-Along Details

Preferred date *

Alternate date

Riding more than one day?

Add each additional date here and submit once, no need to fill out the form again for every day.

Shift preference

Station preference

Reason for ride-along / what you hope to learn

Emergency Contact

Name

Phone

Relationship

What to Expect · Dress Code · Conduct

From CCCFD SOG 1023.10 / 4.20. Please read before signing.

DRESS CODE

Uniform shall consist of a single solid-colored collared shirt, dark pants, and dark shoes appropriate for this type of work. Jackets and/or sweatshirts may be worn of a single dark color and/or as approved by the on-duty shift officer. All required colors of apparel must be solid in color. (School/Program uniform shirt is preferred if provided.)

Apparel displaying pictures, words, slang names, or inappropriate material will not be allowed or tolerated.

PROHIBITED ACTIVITIES

While riding as an observer or student, you may NOT:

Operation of any vehicle or department apparatus at any time.
Provide any firefighting or medical activity of any type.
Wearing or displaying uniform parts, badge, or other identification that may distract away from current department members.

OBSERVER / STUDENT CONDUCT

Observers/Ride-Alongs shall remain under the direct supervision of their assigned crew and shall comply with all directions and requests made by said crew.

Observers/Ride-Alongs shall not interfere or attempt to perform any Fire/EMS activity while either in an apparatus or on the scene of an incident unless directed by the crew supervisor and within the student/observer's legal scope of ability.

Should the observer/ride-along indicate a desire to cease participation in the ride-along at any time, the crew shall return the observer/ride-along to the station as soon as possible.

Observers/Ride-Alongs are expected to be an active member of the crew for the day whether in the station or on the scene of a call. This involves participation in trainings, public education details, inspections, pre-plan inspections, daily apparatus checks of the apparatus or ambulances, and any other details as put forth by the on-duty shift officer.

HIPAA Training

SOG 1023.10 requires every observer/ride-along to complete a HIPAA training video as part of orientation. If you have not already watched it, the on-duty crew will play it for you at the start of your shift. Once completed, the same training does not need to be repeated for future shifts.

I have watched the HIPAA training video, or I will complete it during my pre-shift orientation with the crew. *

Confidentiality & Release

CONFIDENTIALITY STATEMENT

Given the nature of the Central Campbell County Fire District's obligation to provide emergency medical services, it is imperative that all members, employees, guests, trainees, and others who may participate in the activities of the Central Campbell County Fire District maintain the privacy rights of all patients of the Central Campbell County Fire District as well as the confidence of any and all patient information obtained in the course of carrying out the duties of emergency medical services.

When rendering such services, members, employees, guests, trainees, and others who may participate in the activities of the Central Campbell County Fire District may obtain protected patient health information in a variety of forms such as electronic, oral, written, or photographic. This information shall be deemed confidential and protected by federal and state laws that prohibit its unauthorized use or disclosure for treatment, payment, health care operations or personal gain.

Therefore, it shall be the policy of the CENTRAL CAMPBELL COUNTY FIRE DISTRICT to further prohibit the unauthorized use or disclosure of protected patient health information to anyone outside the department. Furthermore, discussions of protected patient health information by members, employees, guests, trainees, and others who may participate in the activities of the Central Campbell County Fire District should be limited to instances directly related to the delivery of essential services.

I hereby agree that I will comply with any and all confidentiality policies and procedures set in place by the Central Campbell County Fire District. If, at any time, I knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to notify the Fire Chief and/or his designee of the Central Campbell County Fire District immediately. I agree to return any and all protected patient health information in my possession at the end of every incident.

I agree to all the conditions of my ride along as set forth in this agreement.

I have read and agree to the Confidentiality statement. *

RELEASE & WAIVER OF LIABILITY

WHEREAS I, the undersigned, do hereby acknowledge that on _____ day of __________, 20___, not being a member of the Central Campbell County Fire District, I have made a voluntary request to ride as a guest in a vehicle/apparatus assigned to the Central Campbell County Fire District and to accompany members of the department during the performance of their official duties; and

WHEREAS, the Central Campbell County Fire District is willing to allow me to ride as a guest in a vehicle/apparatus assigned to that department and to accompanying members of said department during the performance of their duties.

I DO HEREBY AGREE THAT IN CONSIDERATION FOR THE OPPORTUNITY TO PARTICIPATE IN THE STUDENT/OBSERVER PROGRAM:

That I am aware that the work of the Central Campbell County Fire District is inherently dangerous and that I may be subjected to the risk of death, personal injury/illness or damage to my property by accompanying members of the department during the performance of their official duties. I freely, voluntarily, and with such knowledge, assume the risk(s) associated with such activities, including but not limited to: death, personal injury/illness, or property damage arising from or in any way connected with the use of weapons, unlawful acts or forcible resistance, law violators or suspected law violators, assault, riot, breach of peace, fire, explosives, gas, electrocution, or the escape of hazardous substances, or the sustaining of injury in any other way while accompanying members of the department during the performance of their official duties.

That I exempt and release the Central Campbell County Fire District, its officers, members, and employees and their sureties, all members of the Central Campbell County Fire District and each of them from any and all liability, claims, demands, or actions or causes whatsoever arising out of any damage, loss, or injury/illness to me or to my property incurred while riding in any vehicle/apparatus assigned to the Central Campbell County Fire District or while accompanying members of the Central Campbell County Fire District during the performance of their official duties, or while on the premises of the department, including such loss, damage, or injury/illness resulting from the negligence of the Central Campbell County Fire District and their sureties, and each of them, or from some other cause.

I further, with the intention of binding my spouse, my heirs, legal representatives, executors, administrators, and assigns, do hereby voluntarily and knowingly remise, release, defend, indemnify, forever discharge, hold harmless, and covenant not to sue the Central Campbell County Fire District, its officers, employees, and members of the Central Campbell County Fire District, their sureties and each of them, against any and all manner of action, causes of action, suits, debts, claims, demands, damages, judgements, or liability or expenses of any kind that incurred or arising by reason of any actual or claimed negligent or wrongful act or omission by me or by them while riding in any vehicle/apparatus assigned to the Central Campbell County Fire District or while accompanying any member(s) of said department during the performance of their official duties.

I also understand and acknowledge that this event will be conducted in whole or in part on privately owned property. In the event that I, or someone for whom I am responsible, causes damage to any property beyond that which is expected in the normal course of an event of this nature, I agree to defend, indemnify, and hold harmless the Central Campbell County Fire District, its officers, employees, and members of the Central Campbell County Fire District, their sureties and each of them, from any and all claims made as a result of the damage. I further agree and understand that this indemnification and hold harmless clause shall survive the below referenced termination clause and shall continue in full force and effect until six months after any applicable statutes of limitations shall have expired.

The provisions of this release shall prevail until revoked in writing to me, but in no event shall these provisions extend beyond past 124 calendar days or four (4) calendar months, whichever is the longer time frame, from the date this release was signed.

I hereby represent that I have carefully read and fully understand the contents and provisions of this document and have voluntarily and knowingly executed said release with the express intention of effecting the extinguishment of claims and liability herein designated. I also understand that it is my responsibility to thoroughly and completely follow instructions given to me by representatives of the Central Campbell County Fire District and my participation may be terminated at any time for breach of instructions. I do sign this document of my own free will.

I have read and agree to the Release. *

Signature

Typed signature (your full legal name) *

Date

Typing your name above serves as your electronic signature on this application. If the applicant is under 18, the parent/guardian named above signs on their behalf.