Ride-Along Waiver

Assumption of Risk, Waiver, and Release of Claims

Select all that apply (required)

EMT / Paramedic Training Ride-Along

Citizen Ride-Along — Employment Application

Citizen Ride-Along — General / Community

Other:

B2 Fire Personnel Point of Contact (required)

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)

PROGRAM RULES & CONDUCT

In consideration of being permitted to participate, I agree with the following. Check each box to confirm your understanding and agreement. (required)

Observer Role: I am participating strictly as a civilian observer and am prohibited from performing any emergency, medical, firefighting, or rescue functions at any time.

Stay With Vehicle: I will remain in or near the emergency response vehicle at all times unless expressly directed otherwise by the fire officer in charge, and I will comply with all instructions immediately.

Confidentiality: I will not disclose any confidential information, including Protected Health Information (PHI), obtained during my participation. I agree to comply with all HIPAA requirements in Section 5 of this form.

Age & Eligibility: I am 18 years of age or older.

Media Consent: I consent to photographs, video, or media coverage of my participation for BCFPD 2 public relations or educational purposes without personal compensation. (Cross out if you do not consent.)

ASSUMPTION OF RISK & RELEASE OF CLAIMS

RISKS I AM VOLUNTARILY ASSUMING: I am applying to participate in the BCFPD 2 Ride-Along Program and understand that participation involves exposure to inherently dangerous conditions associated with emergency response operations. (Check each box to confirm your understanding and agreement.) (required)

Emergency Vehicle Operations: I assume all risks arising from emergency vehicle response, including high-speed driving, sudden stops, emergency maneuvering, and unpredictable road and traffic conditions.

Hazardous & Traumatic Conditions: I assume the risk of exposure to traumatic scenes, graphic injuries or fatalities, hazardous materials, smoke, toxic substances, communicable diseases (including bloodborne pathogens and airborne illnesses), extreme temperatures, and structural or environmental hazards.

Personal Injury & Property Loss: I assume all risk of personal injury including but not limited to falls, strains, burns, cuts, respiratory harm, bone or joint injury, head or neck injury, psychological stress, and death, as well as any loss of or damage to my personal property.

EMS / Patient Proximity — EMT & Paramedic Rides: I assume additional risks from proximity to patients, including exposure to infectious disease, bodily fluids, and emotionally distressing medical situations.

LEGAL TERMS I AM AGREEING TO: (Check each box to confirm your understanding and agreement.) (required)

Waiver & Release of Claims: On behalf of myself and my heirs, executors, administrators, and assigns, I hereby waive, release, and forever discharge BCFPD 2, its Board of Directors, officers, employees, agents, and volunteers from any and all claims, liabilities, or causes of action arising from my participation in the Ride-Along Program, including claims based on the ordinary negligence of BCFPD 2 or its personnel.

Indemnification: I agree to indemnify, defend, and hold harmless BCFPD 2 and its personnel from any claims, costs, attorney’s fees, or damages arising from my own actions or conduct during participation.

Property Damage: I agree to reimburse BCFPD 2 for any damage I cause to District equipment or property within thirty (30) days of receiving written notice of the amount owed.

Medical Authorization: In the event of an emergency, I authorize BCFPD 2 officials to arrange any medical treatment deemed necessary for my immediate care. I understand I am solely responsible for all resulting costs.

HIPAA 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). (Check each box to confirm your understanding and agreement.) (required)

PHI Definition: PHI is any individually identifiable health information including information about a person’s past, present, or future physical or mental health, healthcare received, or payment for healthcare. PHI includes identifiers such as name, address, date of birth, and Social Security number.

No Unauthorized Disclosure: HIPAA prohibits the unauthorized disclosure of PHI to anyone outside the organization, whether oral, written, photographic, video, or electronic.

Full Compliance: I agree to comply with all BCFPD 2 confidentiality policies throughout the entirety of my participation in the Ride-Along Program.

Penalties: Civil penalties for unauthorized PHI disclosure may reach $100 per violation (up to $25,000 annually). Criminal penalties for intentional violations include fines of $50,000–$250,000 and up to 10 years imprisonment.

Breach Reporting: If I knowingly or inadvertently breach patient confidentiality, I will immediately notify the BCFPD 2 Training Chief. I understand a breach may result in termination of my ride-along privileges and may be reported to my sponsoring agency, if applicable.

ACKNOWLEDGMENT & SIGNATURE

I acknowledge by checking all boxes: (required)

I have read this entire Agreement in full.

I understand its legal effect.

I have checked all applicable boxes above expressly assuming each risk and agreeing to each legal term.

I am signing freely and voluntarily without inducement or coercion.

Signature/Full Name (required)

Date (required)

Copy of ID is REQUIRED (required)

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