Ride-Along Release Form

REQUEST/WAIVER FOR PARTICIPATION

PARTICIPANT’S NAME: (print) __________________________ DATE OF BIRTH: __________

ADDRESS: ____________________________________________ PHONE NO.: __________

CHECK ONE (1) - PROGRAM AFFILIATION OF RIDER:

 College Internship; name of college __________

 Participation in Government; name of high school __________

 Fire District Non- Fire Related Employee; position __________  Other Program Affiliation: __________

 Relative; specify son/daughter/spouse, etc.

 Requested by Fire Officer

 other; specify ______________________________

Date(s), time(s) and/or officer requested for RIDE-ALONG (if known)...