By submitting this form you agree to adhere to the guidelines listed on the Ride-Along Information page and that you meet the eligibility requirements for applying.
This form is for Ride along at LF3 Clarksville. Please select your second choice here:LifeFlight 1 LebanonLifeFllight 2 TullahomaLifeFlight 4 Mt PleasantLifeFlight 10 BNA Preferred Date(s)*:* Please list a few dates you are available. If you are NOT available oncertain dates, please list them in the Comments section at the end of this form. Have you flown with us before: Yes NOIf Yes, when: What do you expect to gain from your ride-along experience? Requestor Age: First Name:Last Name:Email:TelephoneHome:Cell:AddressStreet:PO, Etc:City:State: -SELECT-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukonAmerican SomoaGuamMilitary - AAMilitary - AEMilitary - APPuerto RicoVirgin IslandsNon-USZip:Emergency Contact PersonFirst Name:Last Name:Relationship:TelephoneHome:Cell:AddressStreet:PO, Etc:City:State: -SELECT-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukonAmerican SomoaGuamMilitary - AAMilitary - AEMilitary - APPuerto RicoVirgin IslandsNon-USZip:Weight:Waist Size (inches):(Not to exceed 250 pounds.)(If waist size is greater than 44 inches you will not be able to be safely and securely fastened into the seatbelts of the aircraft.) Employer:Title: If you are affiliated with a hospital, EMS or other public response service, please provide the following information:Provider Level*Agency Affiliation (hospital, agency, etc.) -SELECT-First ResponderEMT-BasicEMT-IVEMT-ParamedicRNNPMDRTDispatcherOtherDept. or UnitCityState -SELECT-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukonAmerican SomoaGuamMilitary - AAMilitary - AEMilitary - APPuerto RicoVirgin IslandsNon-US* if your Provider Level is not listed, please select 'other' and include it in the 'Remarks' blockMedical History: Do you have a history of any of the following?Yes No Seizure DisorderYes No DiabetesYes No Are you pregnant?(Only eligible to ride during the 1st trimester of pregnancy)Yes No Any other significant health issues?Please explain any 'Yes' answers in Medical History:If any of the above conditions are marked 'Yes', the participant must provide a letter from their physician providing medical clearance for their application in the Ride-Along program.Comments/Remarks: (please be brief)Release, Waiver of Liabilityand Statement of Confidentiality I request to participate in the Vanderbilt University Ride-along Program with LifeFlight. I have been advised of and understand the risks and dangers associated with participation in this emergency air medical program. Nonetheless, I assume the inherent risks by voluntarily participating in the Ride-along Program. In consideration of Vanderbilt offering this opportunity and allowing me to participate in this activity, the receipt and sufficiency of said consideration being hereby acknowledged, except for the usual employee benefits, including Worker's Compensation, to which I may be entitled, I hereby release, relieve, discharge and hold harmless Vanderbilt, it's officers, trustees, employees, and representatives from any and all liability or claim of liability, whether for personal injury, property damage, or otherwise, arising from or in connection with my participation in this activity or any travel associated with this activity. In addition, I agree to abide by all rules and regulations applicable to the Ride-along Program. I understand and agree that patient confidentiality is to be maintained at all times. I also understand and agree that at no time will I provide direct patient caring during my participation in the Ride-along Program, unless, as an attending physician, I am requested to do so by the flight nurse. I further verify, that I have no medical condition that would in any way interfere with the ability of the crew or program to provide patient care or complete a mission. CONFIDENTIALITY STATEMENT! As a Ride-a-long participant, who will be observing at the Vanderbilt University Medical Center and LifeFlight Program, it is important for you to understand that patients have the right to privacy and confidentiality. You must respect the rights of our patients and must not discuss any names or personal information which you may learn about a patient as you observe the program. (Please press submit only one time! )
This form is for Ride along at LF3 Clarksville. Please select your second choice here:
LifeFlight 1 LebanonLifeFllight 2 TullahomaLifeFlight 4 Mt PleasantLifeFlight 10 BNA
Preferred Date(s)*:
* Please list a few dates you are available. If you are NOT available oncertain dates, please list them in the Comments section at the end of this form.
Have you flown with us before:
Yes NO
If Yes, when:
What do you expect to gain from your ride-along experience?
Requestor Age:
First Name:
Last Name:
Email:
Telephone
Home:
Cell:
Address
Street:
PO, Etc:
City:
State:
-SELECT-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingYukonAmerican SomoaGuamMilitary - AAMilitary - AEMilitary - APPuerto RicoVirgin IslandsNon-US
Zip:
Emergency Contact Person
Relationship:
Weight:
Waist Size (inches):
(Not to exceed 250 pounds.)
(If waist size is greater than 44 inches you will not be able to be safely and securely fastened into the seatbelts of the aircraft.)
Employer:
Title:
If you are affiliated with a hospital, EMS or other public response service, please provide the following information:
Provider Level*
Agency Affiliation (hospital, agency, etc.)
-SELECT-First ResponderEMT-BasicEMT-IVEMT-ParamedicRNNPMDRTDispatcherOther
Dept. or Unit
City
State
* if your Provider Level is not listed, please select 'other' and include it in the 'Remarks' block
Medical History: Do you have a history of any of the following?
Yes
No
Seizure Disorder
Diabetes
Are you pregnant?
(Only eligible to ride during the 1st trimester of pregnancy)
Any other significant health issues?
Please explain any 'Yes' answers in Medical History:
If any of the above conditions are marked 'Yes', the participant must provide a letter from their physician providing medical clearance for their application in the Ride-Along program.
Comments/Remarks: (please be brief)
Release, Waiver of Liabilityand Statement of Confidentiality I request to participate in the Vanderbilt University Ride-along Program with LifeFlight. I have been advised of and understand the risks and dangers associated with participation in this emergency air medical program. Nonetheless, I assume the inherent risks by voluntarily participating in the Ride-along Program. In consideration of Vanderbilt offering this opportunity and allowing me to participate in this activity, the receipt and sufficiency of said consideration being hereby acknowledged, except for the usual employee benefits, including Worker's Compensation, to which I may be entitled, I hereby release, relieve, discharge and hold harmless Vanderbilt, it's officers, trustees, employees, and representatives from any and all liability or claim of liability, whether for personal injury, property damage, or otherwise, arising from or in connection with my participation in this activity or any travel associated with this activity. In addition, I agree to abide by all rules and regulations applicable to the Ride-along Program. I understand and agree that patient confidentiality is to be maintained at all times. I also understand and agree that at no time will I provide direct patient caring during my participation in the Ride-along Program, unless, as an attending physician, I am requested to do so by the flight nurse. I further verify, that I have no medical condition that would in any way interfere with the ability of the crew or program to provide patient care or complete a mission. CONFIDENTIALITY STATEMENT! As a Ride-a-long participant, who will be observing at the Vanderbilt University Medical Center and LifeFlight Program, it is important for you to understand that patients have the right to privacy and confidentiality. You must respect the rights of our patients and must not discuss any names or personal information which you may learn about a patient as you observe the program. (Please press submit only one time! )
