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EMS Ride Along Request

  1. EMS Ride Along Request

  2. I am requesting the opportunity to ride with the members of the Deer Park Volunteer Fire Department EMS division. This tour is totally voluntary on my part and I release the Deer Park Volunteer Fire Department, the members of said department, and/ or the City of Deer Park, Texas from any liability and all claims against them, individually or collectively, for any injuries which might result during the time period which I will be participating as an observer or Emergency Medical Student.

  3. Additionally, I understand that activities witnessed or performed during this tour shall remain confidential in efforts to protect the privacy of individuals treated and transported by the Deer Park Volunteer Fire Department and its members. I shall not release any information regarding patient history, names, ages, addresses, or personal identification data at any time.

  4. This program is offered to me for the sole purpose of learning and experiencing emergency medicine and shall not be used for any other purpose. I will be riding as an obeserver/ EMS student and will be permitted to assist EMS personnel as directed by the medic in charge or as described to me at the beginning of the tour.

  5. During my tour with the Deer Park Volunteer Fire Department, I understand that I must remain at my assigned station while not on a response and will be assigned a department member as a contact during the tour period. Any display on my part that is not positive towards the crew or individuals treated by cre w members may result in an immediate suspension from my assigned tour.

  6. Consent*

  7. First and Last Name

  8. Disclaimer

    Please note that this is a request and not a guarantee. All requests are honored in the order they are received. You will be contacted by a DPVFD representative to confirm and approve your request.

  9. For Internal Use Only

  10. Leave This Blank:

  11. This field is not part of the form submission.