Ride Along Request Form

Ride Along Request Form

We are thrilled you chose LifeLine EMS for your Ride Along to experience firsthand the dynamic world of EMS. We are passionate about supporting your educational journey and providing you with invaluable insights into the EMS field. Join us and gain practical, real-world experience as you ride alongside our dedicated professionals. We look forward to having you with us!

Instructions (please read first)

Please complete the following fields and ensure all information is entered correctly to schedule your Ride Along. Upon completion of this form, a waiver will be sent to you via DocuSign (docusign.net, from Aster Martinek). Please check your spam/junk email box for the waiver. Failure to complete this process will delay scheduling.

First Name*

Last Name*

Age*

15 - 17 years old

18 +

Phone #*

Phone

LifeLine EMS uses emails to confirm scheduled shifts. Please provide an active email below.

Email*

Emergency Contact

Please provide full name, relation, and phone number.

If you are a minor a legal guardians email is required

INSTRUCTORS ARE NOT TO BE PLACED IN THIS FIELD, THIS SHOULD BE FOR IMMEDIATE FAMILY OR GUARDIANS

Emergency Contact/Guardian Name*

Please provide First and Last name

Emergency Contact/Guardian Relation*

Emergency Contact/Guardian Phone number*

Phone

Guardian Email*

This is required for minors as we need to send a release of liability form. Both the minor and guardian must sign this form for a ride along to be completed.

EMS Program*

If you do not see your school listed then please type in the name of the program, make sure to hit enter to complete.

Select or enter value

How many hours do you need to schedule?*

When do you graduate EMT School:*

Do you have availability to do your ride along overnight?*

YES

Date(s) of availability.*

You will be scheduled based on the availability you provide here. If you need to update your availability you can email ridealong@lifeline-ems.com before you are scheduled. Changes and requests received after your are scheduled will not be accommodated.

Please select all bases that will work for you for*

Anaheim

Arcadia

Commerce

Downey

East LA/Boyle Heights

Glendale

Hollywood

Laguna Hills

Los Alamitos

North Hollywood

Pomona

San Gabriel Valley

Santa Ana

Tarzana

Whittier

Are you planning to work in EMS?*

Yes

Why are interested in becoming an EMT?*

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