Full Legal Name*
Date of Birth*
City, State, Zip*
Requested Ride-Along Dates:*
Relation to Rider*
Contact Phone Number*
City, State, Zip*
There are inherent risks involved in participating in a ride-along and all riders are required to fully read, understand, and agree to the instructions and waivers in this packet. with the appropriate safeguards, non-EMS personnel can ride safely and gain a good perspective on EMS operations and the types of services the Massena Rescue Squad provides.
All riders are expected to wear appropriate attire while on a ride-along. This includes: dark navy blue or black pants/jeans (no shorts) and black shoes or boots. Dark navy blue t-shirt is preferred and it must not contain advertising or emblems. Massena Rescue Squad jackets arl available to riders.
All riders are expected to strictly adhere to the safety and conduct guidelines outlined below.
A rider who violates any safety or conduct guideline may have their ride-along terminated.
Please carefully read and agree to the following statement.
I have read the above Massena Rescue Squad ride-along guidelines and I agree to abide by them. I understand that a violation of any of the above policies is grounds for termination of my ride-along. I also consent to the use of my photograph, name, and address by the Massena Rescue Squad to publicize and make reports about this ride-along program.
Federal law prohibits the unauthorized sharing of patient information. Patient information such as their name, demographic data, medical condition, or any other identifying information is strinctly confidential and is NOT to be disclosed, in any form, to anyone except ambulance personnel and others who are authorized under HIPAA to receive such information. Riders MUST treat ALL patient information as confidential and consult the ambulance crew with any questions regarding HIPAA laws.
I will treat all patient identifiable information as strictly confidential. This information includes, but is not limited to, the patient's name, address, telephone number, date of birth, age, social security number, medical condition, treatment received, and past medical history. I will not share, in any form, patient identifiable information with friends, family, or others that are not directly involved with patient care. If, at any time during or after the ride-along, I am asked a question about a patient, I will refer the asking person to the ambulance crew or fire department officers. I understand that if I disclose patient identifiable information, even unintentionally, I may be subject to civil or criminal penalties.
In participating in a ride-along with the Massena Volunteer Emergency Unit, Inc. (DBA: Massena Rescue Squad), the undersigned waves any and all rights that he or she might have to claim damages, compensation, or remuneration in any form from the Massena Rescue Squad, the Town of Massena, and its employees arising from or associated with the ride-along.
These rights specifically pertain to any injuries to the applicant of this form while he/she is a passenger in any ambulance or other vehicle operated by the Massena Rescue Squad or the Town of Massena, or to any injuries sustained in the course of responding to a call including while en route, on scene, or at any facility.
Riding with an ambulance crew on an emergency response is inherently dangerous and cannot be made safe. The applicant of this form understands this and has elected to participate in the ride along program with full understanding and knowledge of the inherent dangers involved. The inherent dangers associated with a ride-along include, but are not limited to: accidents involving the ambulance, negligent or intentional tortuous acts by third party persons, exposure to communicable diseases, and various accidents during the provision of emergency medical treatment. The applicant also understands that they may witness traumatic injuries or events that may leave a lasting impression.
As used herein, the word "injuries" shall include bodily injuries, injuries to personal properties, mental anguish, emotional distress and/or death resulting from any such bodily injuries. All reference herein to the applicant shall include not only the individual applying, but also his or her personal representative, heirs, and survivors.
In addition to waiving rights as specified above, the applicant, by submitting this form, represents that he/she has read and understood this document; that he/she is 18 years of age or older; and that he/she is fully aware of the risks inherent in participating in the ride-along. The applicant also acknowledges that if any single provision of this Waiver or Rights is declared unenforceable that such declaration has no effect on the enforceability of the remainder of the Waiver. This Waiver of Rights shall become effective upon its submission.