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 are you affiliated with?*

    1. WSU
    2. UD
    3. MVH
    4. GVH
    5. CMC
    6. WPAFB
    7. GMH
    8. KMC
    9. DFD Explorer
    10. Other
14. If you selected other above, please specify.*
16. What is your title?*

    1. Student
    2. Resident
    3. Explorer
    4. Nurse
    5. Observer
    6. Other
18. If you selected other above, please specify or put n/a.*
20. What date would you like to ride the medic?*
    What date would you like to ride the medic?
21. What time would you like to ride the medic?*

    1. 0700-1500
    2. 1500-2300
    3. Both time slots
23. Which medic is your first choice?*

    1. Medic 2
    2. Medic 11 (only available Tue, Thur, & Sat)
    3. Medic 13 (only available Tue, Thur, & Sat)
    4. Medic 14 (only available Tue, Thur, & Sat)
    5. Medic 15
    6. Medic 16
    7. Medic 18
    8. Other

    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.

25. If you selected other above, please specify.*
27. 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 dominika.kozlowski@daytonohio.gov prior to requesting a Ride Along.

Leave This Blank:


29. 1. Receive an email copy of this form.
30. Email address

    This field is not part of the form submission.

31. Submit

* indicates a required field