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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.
Examples: REMS Council, Northern Virginia Community College, etc...
Our organization staffs ambulances from 5:30 am till 6:00 pm, Monday through Friday. Considering this schedule, what would be you best availability?
Please list the specific dates your are available.
Please document any details associated with the hours, procedures, and/or contacts that you need to complete.
This field is not part of the form submission.
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