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Student Clinical Ride Along Request

  1. EMS Student Clinical Ride Along Request
    This form is to be used by Emergency Medical Service (EMS) Students enrolled in a current National Registry and/or Virginia Office of EMS approved training course to request a ride along. Please complete the information below and we will be in contact regarding availability. Please note that by completing this request a ride along is not guaranteed, it must still be approved by staff and officially scheduled. This form is only a request to ride for your student clinical hours. Once your ride along is officially scheduled you will need to complete a liability release statement, watch our HIPPA training video, sign a HIPPA privacy agreement, and complete any additional requirements as set forth in any agreements the department has with the organization delivering your program.
  2. Examples: REMS Council, Northern Virginia Community College, etc...
  3. Course Type*
  4. Are you required to ride with a REMS Council Preceptor?*
  5. Availability
    Our organization staffs ambulances from 5:30 am till 6:00 pm, Monday through Friday. Considering this schedule, what would be you best availability?
  6. Shifts
  7. Please list the specific dates your are available.
  8. Please document any details associated with the hours, procedures, and/or contacts that you need to complete.
  9. Leave This Blank:

  10. This field is not part of the form submission.