Ride Along Form | Richland Township Fire Department

RICHLAND TOWNSHIP FIRE DEPARTMENT RIDE-ALONG OBSERVER PROGRAM RELEASE

(UPDATED OCTOBER 2013)

Fill out the form below or download & print a PDF

In consideration of my receiving permission from the Richland Twp. Fire Department to enter upon the premises of any fire station or related entity, any other premises owned and/or operated and/or used by any fire station within the Richland Twp. And in further consideration of receiving permission from said Fire Department to participate in a Ride-Along Observer Program, wherein I will be riding in, on, or upon Fire Department apparatus, the undersigned hereby releases the Richland Twp. Fire Department, Richland Twp. Police Department, and any and all agents, officer, servants, employees, attorneys, or other representatives of foregoing from any and all liability, claims, demands, action, and causes of actions, whatsoever, arising out of or related to any loss, property damages, physical injury, contagious disease, or death that may be sustained by me while, in, on, or upon any premises, vehicles or apparatus owned, occupied, or used by the foregoing, or which may be sustained by me while at the scene of any real or apparent emergency situation requiring a response of the Richland Twp. Fire Department, or while commuting to and from the fire station(s) and other points.

I hereby certify that I am duly aware of the risk and hazards, including serious physical injury or death, inherent, upon participating in the Ride-Along Observer Program, that such risks and hazards may exist even in non-emergency situation, and being duly aware of risks and hazards, I hereby elect, voluntarily, to participate in the Ride-Along Observer Program. I hereby assume all risks of loss, damage, and/or injury, including death, that may be sustained by me or by any of my property while participating in the Ride-Along Observer Program.

This release shall be binding upon my relatives, spouse, heirs, distributes, next of kin, executors, administrators, and any other interested parties.

In signing this release, I hereby acknowledge and represent:

that I have read the rules and regulations outlined in the Richland Twp. Fire Department Ride-Along Observer Program.
that I have read this release, understands it, and signs it voluntarily.
that I am over eighteen (18) years of age and that I am of sound mind and of sound physical health. If under eighteen (18) I will furnish a letter from my legal guardian.
that I am not an agent, servant or employee of another fire department that may be trying to spy or manipulate the Richland Twp. Fire Department in any way, shape or form.
that any injuries or other damage suffered by me will not be compassable by Worker’s Compensation or any other insurance program maintained by the Richland Twp. Fire Department.

I also agree to adhere to the following guidelines:

I will abide by any and all applicable rules and regulations of the Richland Twp. Fire Department.
I will not ride or attempt to ride or use or attempt to use, any Richland Twp. Fire Department vehicle or apparatus until such time as a duly authorized officer has reviewed with me the procedures for riding or using name.
I also agree that I have no physical or mental handicaps that may affect me during my participation in this program or which may be aggravated by my participation in this program.
Despite the Richland Twp. Fire Department’s knowledge of this disability or defect, I agree that their continuing grant of permission for me to participate in this program shall not subject them to ANY liability.
I also authorize and instruct the Richland Twp. Fire Department or their authorized representatives to notify the following person in case of any accident in which I am involved while participating in this program or while I am commuting to and from the fire station(s) or other points.

I have not been denied membership status in the Richland Twp. Fire Department for criminal record, background, or medical reasons.
If I have been denied membership in another fire/rescue organization outside of the Richland Twp. Fire Department, said reason(s) will be disclosed upon request to the Richland Twp. Fire Department authorized representative.
Should I be a bona fide member of a fire and/or rescue association or department, I will disclose the name of such organization.

Upon request, a medical waiver statement from a physician must be submitted to substantiate fitness to perform the Ride-Along Observer status on-the-scene of emergency operations.

This release form shall become a permanent record of the Richland Twp. Fire Department.

Expected Ride-Along Observer dates:

At the end of this period, a new release form must be obtained.

Approved by: