General Information

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General Information

Name *

Email *

Phone *

Home Address *

Employer (if applicable)

Student? *

Yes

Required

If you are a student what is your current course of study?

Current grade level

Have you ever participated in a ride-along program *

Yes (if yes please specify below)

Required

Previous ride-along experience

How did you hear about our program? *

Relative

Friend

Current member of our department

Community Event

Other

Please tell us why you would like to participate in our program. *

What is your availability? (check all that apply) *

Daytime

Nightime

Weekdays

Weekends

Emergency Contact (please include name and contact phone) *

LIABILITY STATEMENTS AND AGREEMENTS *

AGREEMENT ASSUMING RISK OF INJURY OR DAMAGE AND INDEMNITY AND HOLD HARMLESS

I am over the age of eighteen (minors must have written permission and a signed waiver from parent of guardian)

By checking this box the applicant has made a voluntary request for permission to ride as an observer in a Fortuna Volunteer Fire Department vehicle at a time when such vehicle is operated and manned by members of the Fortuna Volunteer Fire Department, and has further requested permission to accompany a member of said Department during the active performance of his/her official duties as a Duty Officer.

By checking this box the applicant agrees to and shall indemnify and save harmless the City of Fortuna, Fortuna Fire Protection District, Fortuna Volunteer Fire Department, It's officers and agents, from all suits or actions of every name and description brought for, or on account of injuries or damages received or sustained by the undersigned while riding with or accompanying Fortuna Volunteer Fire Department while in the performance of their duties.

Required

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