Form Center

2. 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.
4. First Name*
5. Last Name*
7. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Email*
16. Phone Number *
18. Fire and/or Rescue Agency Affiliation (If Applicable)
22. Who is your course through?*
    Examples: REMS Council, Northern Virginia Community College, etc...
24. Course Start Date*
    Course Start Date
25. Course End Date*
    Course End Date
26. Last Date for Clinicals*
    Last Date for Clinicals
27. Test Date
    Test Date
29. Name of Course Coordinator*
31. Course Coordinator's Phone Number*
32. Course Coordinator's Email*
34. Course Type*

    1. Emergency Medical Responder
    2. Emergency Medical Technician
    3. EMT-Advanced

    1. EMT-Intermediate
    2. Paramedic
36. Your Current OEMS Certification Number
38. Are you required to ride with a REMS Council Preceptor?*

    1. Yes

    1. No
42. 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?
44. Shifts

    1. Mondays, 0530-1800
    2. Tuesdays, 0530-1800
    3. Wednesdays, 0530-1800

    1. Thursdays, 0530-1800
    2. Fridays, 0530-1800
46. Dates*
    Please list the specific dates your are available.
48. Questions / Comments / Additional Information
    Please document any details associated with the hours, procedures, and/or contacts that you need to complete.
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

* indicates a required field