Ride-Along Application

APPLICANT INFORMATION

Applicant Name

Email Address*

Phone Number

Phone Type
MobileHome

Home Address

Street Address

City

Zip Code

Please provide 2-3 dates that you would like to complete your ride-along.

LIABILITY WAIVER

The intent of the Superstition Fire & Medical District Ride-Along Program is to provide an opportunity for individuals to accompany SFMD personnel to observe them in the performance of their duties.

The rider is aware that such duties may create a hazard to the rider and/or to the firefighters.

The Fire District agrees to permit the rider to "Ride-Along" with Superstition Fire & Medical District personnel on date(s) to be determined.

The rider agrees to the following:
• In consideration for the privileges of accompanying a crew, I do hear by hold harmless, release and discharge the District from all claims, present and future, known or unknown, in any manner arising out of my participation in the Ride-Along Program. I specifically waive any and all rights I have or may have in the future under the Arizona and/or Federal Tort Claims Act or any other statute.
• I agree to comply fully with any directives, orders, or requests from Fire District personnel during the Ride-Along Program.
• I agree to strictly observe the confidentiality of District and patient records. Any breach of confidentiality will result in the termination of privileges and may result in legal action against me.
• I have read and understood this release agreement and all of its terms. I have executed it voluntarily and with full knowledge of its significance.
• I understand that riding along with Superstition Fire & Medical District personnel may expose me to risks such as hazardous material, infectious diseases, traumatic situations, etc.
• I understand that I must be able to function in such a way as to not impede the functions of the crew as they perform routine or emergency duties.

AFFIRMATIONS

I affirm that I am at least 18 years of age.
I understand that I will need to show ID to verify my name and age prior to beginning my ride-along.
I affirm that I have watched the required HIPAA training video.
I understand that during my ride-along, I may encounter the protected health information (PHI) of patients being treated by Superstition Fire & Medical District personnel.
I agree that I will keep all PHI confidential and abide by the HIPAA laws as described in the training video.
I acknowledge that I have read and understand all the statements in the liability waiver.
By submitting this application, I affirm that the information in this application is correct to the best of my knowledge.

Please leave this field empty.

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