Ride-Along Agreement and Waiver

APPLICATION

Programs: (required)

Training Ride-Along: EMT, Paramedic

Community Service Ride-Along

Other:

Applicant’s/Participants Name (first, last): (required)

Date of Birth (DOB): (required)

Driver License #: (required)

Mailing address: (required)

City, State, Zip Code: (required)

E-mail: (required)

Phone: (required)

Days or Dates Available: (required)

Any Medical Conditions: (required)

Emergency Contact Name (required)

Emergency Contact Relationship: (required)

Emergency Contact Phone Number: (required)

RIDE-ALONG AGREEMENT AND WAIVER

As a ride-along with a Benton County Fire District 2 (BCFPD 2) crew members in an emergency response vehicle, a ride-along participant shall not participate in any emergency activity. A ride-along participant rides in the capacity of an observer only and is under the complete control of the fire officer at all times. In consideration of this application I agree to the following by checking all boxes: (required)

I am participating as a civilian and strictly prohibited from performing any emergency medical or firefighting functions.

I will not divulge any confidential information that I learn while participating in the ride-along program. I will read and complete the attachment, HIPAA Privacy Rule Confidentiality Agreement.

I will remain in the vehicle at all times unless directed by the fire officer in charge.

I am aware of the inherent risks involved and I freely and knowingly assume all risks to my person and/or property.

I am 18 years of age or older.

That I, my heirs, executors and assigns indemnify and hold harmless BCFPD 2, and any of its employees, for any claims, amounts and/or damages that may arise from my conduct while I am participating in the Ride-Along Program.

RELEASE OF LIABILITY

I am applying to participate in the BCFPD 2 Ride-Along Program (Program) and I agree to the following by checking all boxes: (required)

I understand that participating in the Program referenced above carries dangers and risks and I knowingly assume all risk of any resulting personal injuries including, but not limited to: falling; tripping; bumping; strains and injuries to back, spine, bone, joint, head, neck or muscles; or cuts, scrapes; choking; allergies; heat stroke; heat exhaustion; sunburn or other injuries or death; and any resulting damage to or loss of my property

I waive and relinquish all claims or any basis, including but not limited to negligence, which I may now have or might otherwise make in the future resulting from my participation in the Program against BCFPD 2 and its officers, agents, servants and employees. Further, I agree to indemnify, defend and hold harmless BCFPD 2 against any claims by any person, firm or corporation arising from my participation in the Program referenced above, including claims already made and claims that may be made in the future.

I agree to pay for any damage to District property resulting from my participation in the Program directly to BCFPD 2 within thirty days of receiving a statement of damage owed.

In case of emergency, I authorize the District officials to secure from any licensed ambulance, emergency medical services provider, hospital, physician, and other medical personnel any treatment deemed necessary for my immediate care. I will be responsible for the payment for all care and treatment rendered.

I also give permission for disseminating media coverage of my participation in the Program for public relations purposes without any personal compensation.

This Acknowledgement of Risk and Release is valid for the period set in this agreement.

HIPAA PRIVACY RULE CONFIDENTIALITY AGREEMENT

As a participant in the BCFPD 2 Ride-Along Program, you may become aware of protected health information (PHI) that is confidential in nature. Disclosure of PHI is protected under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). Please indicate your understanding of the following HIPAA information by checking all boxes: (required)

PHI is any “individually identifiable health information,” which includes information about an individual’s past, present or future physical or mental health or condition; the provision of health care to the individual; or the past, present or future payment for the provision of health care to the individual.

PHI includes information that identifies the individual or which can reasonable be used to identify the individual. Individually identifiable information includes many common identifiers such as name, address, birth date, and Social Security number.

HIPAA prohibits the unauthorized disclosure of PHI to anyone outside the organization, whether oral, written, photographic, video or electronic.

I agree that I am required as a ride-along participant with BCFPD 2 to comply with all confidentiality policies during my entire experience with the organization.

I understand that potential civil penalties for unauthorized disclosure of PHI are $100 for each violation, up to a maximum of $25,000 per year for all violations. Criminal penalties can include one to 10 years of prison with financial penalties ranging from $50,000 to $250,000 for violations knowingly committed under false pretenses or with the intent to use PHI for malicious harm, personal gain or commercial advantage.

If I, at any time, knowingly or inadvertently breach these patient confidentiality policies, I agree to notify the Training Chief of BCFPD 2 immediately. In addition, I understand that a breach of patient confidentiality may result in the termination of my privileges to ride with BCFPD 2. It may also include the recommendation by this department for disciplinary action by my sponsoring agency, if applicable.

I acknowledge by checking all boxes: (required)

I acknowledge that I have read this entire agreement and that I understand its legal effect.

I acknowledge and understand this BCFPD 2 Acknowledgement of the Release of Liability. Neither party can orally modify this Acknowledgement of the Release of Liability.

I have read and fully understand the HIPAA confidentiality agreement and agree to all conditions set forth as a condition of my Ride-Along.

Signature/Full Name (required)

Date (required)

Copy of ID is REQUIRED (required)

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