If yes, please add date as well.

Please note that you must be 16 years or older to be considered for a Ride Along.

If you are not a Tacoma, Fife, or Fircrest Resident you are not eligible for a TFD ride along. Please visit your local Fire Department.

Please make sure this is correct, as this is how we will contact you with any information. NOT via phone.

It is important for you to understand that patients have the right to privacy and confidentiality. These rights are protected by Washington State and Federal law. You must respect these rights. That means that what you see, hear, or learn about a patient during the ride-along must not be shared with anyone, except the Tacoma Fire Department personnel who were involved in the incident. After your ride-along is finished, you cannot share or use any information about patients, including names, address, or medical conditions. You will not be allowed to take photographs or videos during the emergency medical incidents. If you agree to abide by these terms, please initial in the box below.

Be aware that firefighters respond to many medical situations. You may observe scenes that may be violent, traumatic, or emotional. If you would like to discuss these possible situations, please inform the Company Officer at the beginning of your assignment. If you agree to abide by these terms, please initial in the box below.

You are expected to dress professionally during your ride-along. This means you must wear dark trousers and a plain shirt with sleeves. Your clothing must be clean and in good repair. You are not allowed to wear denim jeans, shorts, t-shirts, cropped tops, sandals, or any clothing that has writing or pictures. Logos are acceptable as long as the logo represents your school or medical institution. Although wedding rings and watches are allowed, other jewelry is not acceptable. Safety vests will be provided by the Fire Department. If you agree to abide by these terms, please initial in the box below.

Beverages and/or lights snacks are acceptable to have during your ride along. If you agree to abide by these terms, please initial in the box below.

You will be expected to act in a professional, mature manner. You will be responsible to the Company Officer or In-Charge Paramedic. He/she will direct you regarding safety issues and vehicle assignments. Be aware that you may be entering private residences - do not touch or disturb possessions. Again, be aware that confidentiality is required regarding all incidents. Failure to follow the above instructions will result in termination of the ride along.

WHEREAS the Fire Department of the City of Tacoma (TFD) is providing the opportunity for the undersigned to ride in a fire and rescue units with qualified TFD personnel and observe their activities, the undersigend (herinafter Rider) hereby requests permission and authority to participate in said activities. The Rider agrees to this contract voluntarily in consideration for the opportunity to participate in the ride along program. If you agree to abide by these terms, please initial in the box below.

In making this application for permission, the Rider specifically recognizes that there may be inherent danger in such participation and hereby expressly assumes the risk of said danger for any and all such activities. Such dangers include but are not limited to traffic and traffic accidents, exposure to hazardous materials, to blood, to body fluids, to other media capable of transmitting disease, and to agitated people. Moreover, the Rider agreed to use all due caution and to abide by TFD requirements. If you agree to abide by these terms, please initial in the box below.

It is understood and agreed that the Rider's use or uses of any facilities and vehicles owned or maintained by the City of Tacoma (including but not limited to rescue units, fire trucks, equipment, personnel, and resources) and the Rider's participation in any and all rides, and related activities at any location are at the Rider's sole risk. The Rider hereby agrees to release, indemnify and hold harmless the City of Tacoma for any and all claims, damages, actions or causes of action, at law or in equity, arising from the Rider's activities in riding with TFD rescue units or fire trucks, arising from use or uses of City of Tacoma facilities (including equipment, personnel and resources) and arising from or related to the Rider's participation in any and all such activities. If you agree to abide by these terms, please initial in the box below.

It is further understood and agreed that the City of Tacoma is under no obligation to offer or retain the Rider for employment in any capacity or to provide the Rider with further training. If you agree to abide by these terms, please initial in the box below.

The Rider understands that all emergency responses seen are strictly and permanently confidential in nature and no facts relating to them may be used, shared or discussed except with TFD personnel involved in the incident or in discussions authorized by TFD thereafter. The Rider understands that the Rider has no need to acquire personal patient information and agrees that to the greatest extent possible the Rider will refrain from any attempt to gain such information and from engaging in activities that would yield such information. The Rider agrees to comply with all state and federal laws concerning privacy, including the Health Information Portability and Accountability Act (HIPPA). The Rider agrees to read and adhere to all of the confidentiality requirements described in the "Notice of Your Rights to Medical Services" brochure provided in the link below. The Rider agrees to provide all appropriate safeguards to ensure that private medical information obtained or inadvertently acquired is not disclosed. The Rider agrees to report immediately to TFD any intentional or inadvertent disclosure of private medical information. The Rider agrees to return to TFD copies of any private medical information possessed, and to retain no copies of private medical information. If you agree to abide by these terms, please initial in the box below.

The Rider agrees that if any part of this Consent/Waiver and Hold Harmless (Release) is declared unenforceable, said declaration shall have no effect on the enforceability of the remainder of the release. If you agree to abide by these terms, please initial in the box below.

I (Rider) am accepting as written all the terms in the above Application and Consent/Waiver and Hold Harmless. To indicate you final acceptance of all terms please enter your first and last name below.