Oakland Fire Department Ride-Along

Release and Waiver of Claims

Excellence in Service

Participants Legal Name: ____________________________________________________________

Home Address: ______________________________________City: __________________ Zip: ____________

Phone Number: (______)__________________________ Date of Birth: _________________________

Ride Along Beginning Date: _______________ Ride Along Ending Date: _______________

I hereby request ride-along with the Oakland Fire Department for the purpose of ____________________________________

______________________________________________________________________________________________________

I understand that the maintenance of patient confidentiality is the law in the state of California (Confidentiality of Medical Information Act California Civil Code Sections 56-56.16). Ride Along participants will treat PHI (private health information) as strictly confidential. Disclosure of PHI outside of the organizations who are working with the patient is strictly forbidden. No patient information, response documents or copies, on which individually identifiable information such as name, address, SSN, etc shall be removed, disclosed or transmitted off site. Failure to maintain confidentiality will result in termination from the Ride-Along. Remember the “Golden Rule of Patient Care”: What you see here, What you hear here, When you leave here, MUST stay here! I understand that I am placing myself in a position of danger and participation in potentially hazardous activities and in consideration of the fact that I am permitted to Ride Along, I agree to assume that risk.

In consideration of the fact that I am permitted in this program, I hereby release the City of Oakland Fire Department, and any and all agents, employees and officers of the City from liability for any injury, damage, or claim of any kind resulting from an injury, accident, or incident which occurs during my Ride Along regardless of whether the cause is due to the conditions of City equipment, the active or passive negligence of a City employee, or any other cause whatsoever, and I further waive any right to bring any claim, action, legal or otherwise, against the City of Oakland, the Oakland Fire Department, or any agent, employee, or officer of the City for any injury I may sustain. I understand that my presence during incidents may result in my being subpoenaed to testify in court regarding any incidents which I am a witness.

I agree to comply fully with any and all instructions given to my Fire Department personnel.

I agree that approval to Ride Along with this program may be terminated by the Oakland Fire Department at any time.

I hereby declare that I am over the age of eighteen (18) years that this release is binding not only upon myself but upon my heirs, executors, and administrators and assigns.

____________________________ _______________________________ ______________ Participant’s Signature Print Name Date ___________________________ _________________________________ Agency’s Name Authorized Signature of Participating Agency __________________________________________________________ _____________________ Agency’s Address Agency’s Phone Number Approved: ___________________________________________ ______________

Director of Emergency Medical Services Date