2. 

4. I am filling out this form to:*

   1. Schedule a Ride Time
   2. Cancel a Ride Time
6. First Name*
7. Last Name*
9. Phone Number*
10. Email*
12. What organization (school) are you affiliated with?*
14. What is the reason for the request (clinicals, job shadowing)?*
16. What date would you like to ride the medic?*
    What date would you like to ride the medic?
17. What time would you like to ride the medic?*

    1. 0700-1500
    2. 1500-2300
    3. Both time slots
19. Which medic is your first choice? If your ride along does not have a clinical purpose, please choose OTHER and specify the station you are interested in.*

    1. Medic 2
    2. Medic 10
    3. Ambulance 11 (use only if you are an EMT)
    4. Medic 13 (Available Tuesday, Thursday, and Saturday)
    5. Medic 14 (Available Tuesday, Thursday, and Saturday)
    6. Medic 15 (Available Tuesday, Thursday, and Saturday)
    7. Medic 16
    8. Medic 18
    9. Other (use this if this is not a clinical requirement)

    Answer to this question does not guarantee that you will get the spot. You will receive a confirmation email with the medic that is available.

21. If you selected other above, please specify.*
23. Did you complete the Visitor's Identification and Release Form?*

    1. Yes
    2. No

    This form should have been provided to you from your program. If such form has not been filed, you will NOT be able to do the Ride Along.

    You can download this form here. Please complete it and send to john.hurst@daytonohio.gov prior to requesting a Ride Along.

Leave This Blank:


25. 1. Receive an email copy of this form.
26. Email address

    This field is not part of the form submission.

27. Submit

* indicates a required field