Ride Along Form

2. Purpose

   The purpose of the Civilian Ride along Program is to allow citizens the opportunity to see what firefighters encounter on their shift. Should the Fire Chief approve you to ride out with an engine company, you are subject to the rules laid forth by the shift Lieutenant. The Lieutenant at his discretion or his supervisor has the authority to discontinue the ride along at any time that he/she deems it necessary. Once the application has been processed, someone from the administrative office will contact you.

   
   Questions regarding your application or the status of your application, contact: Susan Yount at 512-401-5222 or email [email protected]

6. Personal Information
8. Name*
9. Date of Birth*
11. Address*
13. City*
14. State*
15. Zip Code*
17. Race
18. Sex
20. Phone*
21. Email
23. Occupation
27. Emergency Contact
29. Name
30. Phone
34. Questionnaire
36. Have you ridden with the Department before?*

    1. Yes
    2. No
37. If yes, when?
39. Reason for requesting a ride along?
41. Date Requesting to Ride?
    Date Requesting to Ride?
42. Time requesting to ride*
    Time requesting to ride Start Time

    —

    Time requesting to ride End Time

    Shifts begin at 7:30 am and ride outs must be completed by 8:00 pm

44. Are you requesting a certain Lieutenant or Crew Member?

    Although we will try to accommodate request it may not always be possible.

46. Crew Member
47. Station Number
51. Liability Release
53. In consideration of being allowed to accompany Cedar Park Firefighters on official calls and otherwise participate in the Civilian Ride along Program:

    I, the undersigned, binding my heirs, executors, administrators, and assigns, do hereby release and agree not to hold liable, the City of Cedar Park, its officers, agents, and employees and especially the Lieutenant on duty, from any and all actions, causes of action, claims, demands, costs or damages arising from or resulting from property damage, personal injuries or death sustained by me while participating in the rider program, whether or not such damage or injury was caused or contributed to by any acts or omissions, including negligent acts or omissions, of any other person or persons. I further agree, binding my heirs, executors, administrators, and assigns, to indemnify and defend the City of Cedar Park, its agents, officers, and employees, and the above named officer, from any liability, action, claim, damage, award, or judgment incurred or suffered by the above City or individuals as a result of any act or omission by me or caused in whole or in part by me while participating in the rider program whether or not also caused in part by a person indemnified hereunder. In addition, I make the following representations and acknowledgments upon which I intend the City of Cedar Park to rely:

    1. I understand and agree that while accompanying any engine company during their shift, I am to be only an unarmed, lay observer and bystander, with no active role whatever and that I will have and am given no duties, rights, powers of authority whatever other than those conferred by law upon any other person in like or similar circumstances as may arise from time to time.
       • (EXCEPTION FROM THIS SECTION IS GIVEN TO COMMISSIONED FIREFIGHTERS AND CERTIFIED EMS PERSONNEL)
    2. I realize and agree that while participating in the rider program, I will not be an agent, servant, or employee of the City of Cedar Park and therefore will not be covered by the City of Cedar Park for any workers compensation, death or disability benefits.
    3. I realize and acknowledge that there is an element of danger inherent in riding with firefighters on duty.  It is foreseeable that situations may arise at any time, suddenly and without warning, in which I may be placed in great physical danger.  I knowingly and willingly agree to assume these risks.  I agree that neither the City of Cedar Park, nor any of its officers or employees shall be obligated to take any extraordinary steps to protect my person or to provide a means of withdrawal or retreat for me, and I release them from any duty to do so.
    4. I agree that any information that I may gain, through participation in the program, will be used by me only for my personal education purposes except where I am summoned as a witness in any administrative or court proceeding.
    5. I understand that my participation in the above named program is a privilege subject to revocation at any time by the City of Cedar Park, whose decision in the matter will be binding.

    The Cedar Park Fire Department requires your attire to reflect the professional appearance of our employees, please follow the guidelines below.

    • No shorts are allowed
    • Shirts should not have any pictures, graphics or verbiage on them
    • Closed toe shoes only
    • No piercings should be visible other than standard ear (i.e. no gauges, plugs, etc)
    • Excessive visible tattoos are not allowed

    If you have any questions regarding appearance, please call fire admin 512-401-5222.

57. Signature of Person Requesting Ride
59. Signature
60. Date
    Date
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field