Observers

10/04/2024 | Susquehanna Township EMS, Inc. | Release and Indemnity Agreement

Are you 18 Years of Age or Older?*

Yes
I am Younger than 18 years old.

Applicants Name*

First Last

Name of the Applicant desiring to be granted permission to observe and ride along with Susquehanna Township EMS, Inc.

Applicants Address*

Street Address Address Line 2 City State ZIP Code

Applicants Email Address*

Enter Email Confirm Email

Emergency Contact Information*

Enter an Emergency Contact number

Consent*

I have read and agree to all of the following Release and Indemity Agreement as listed below

I acknowledge that I have requested permission to accompany Susquehanna Township EMS Inc. personnel in the performance of their duties, both in response vehicles and outside of such vehicles. I have been advised of the various dangers involved in emergency medicine work and specifically advised that ambulances and emergency response vehicles are frequently operated under emergency conditions. I have also been advised that I may be exposed to potential perils of life and limb beyond the control of Susquehanna Township EMS, Inc. NOW, THEREFORE, having been fully advised of the dangers inherent in these activities, and in consideration of the privilege being granted to me by Susquehanna Township EMS, Inc to be an observer in a response unit/ambulance, I do hereby, for myself, my spouse, heirs, executor, or administrator, and personal representatives:

A. Assume full responsibility for any personal injury or any damage to my personal property which may occur directly, or indirectly, while in, on, or about any Susquehanna Township EMS, Inc vehicles, the Susquehanna Township EMS, Inc premises or any part thereof of the Susquehanna Township EMS, Inc building/s, or while accompanying any employees of Susquehanna Township EMS, Inc while in the performance of their duties;

B. Fully and forever release and discharge Susquehanna Township EMS, Inc, it's agents, and employees, from any and all claims, demands, damages, rights of actions, or causes of actions, present or future, whether the same be known, anticipated, or unanticipated, resulting from or arising out of my being in, on, or about any Susquehanna Township EMS, Inc vehicles, or at any or all of the premises or places aforesaid, or while accompanying any employee of the Susquehanna Township EMS, Inc as aforesaid;

C. Indemnify and hold harmless Susquehanna Township EMS, Inc, it's agents, and employees for any acts or conduct on my part of whatever kind or nature whatsoever, while in, on, or about any Susquehanna Township EMS, Inc vehicle, it's agents, and employees vehicles, or at any or all of the premises and places aforesaid, or while accompanying any such employee as aforesaid;

D. Agree to defend and to pay any attorney's fees as a result of any action brought by or against Susquehanna Township EMS, Inc, it's agents, and employees, for any acts or conduct on my part of whatever kind or nature whatsoever, while in, on, or about any Susquehanna Township EMS, Inc vehicles, or at any or all of the premises or places aforesaid, or while accompanying any such employee in the course of my ride-a-long.

E. Agree that it is my intention that this Release and Indemnity Agreement be in full force and effect any time after the execution hereof.

Consent*

I have read and agree to adhere to the following rules and regulations

As an observer, you are expected to follow the instructions listed below in order to safeguard yourself and minimize the possibility of interfering with normal activities.

1. All observers shall be at a minimum age of 16 (guardian signature required for observers younger than 18 years) and must demonstrate an active interest in emergency service, either through employment with an emergency service agency or health care provider; or through community involvement or educational experience. Spouses of Susquehanna Township EMS Inc. field personnel may be permitted to ride as well.
2. All observers shall sign a waiver of liability form.
3. Observers must at all times have personal protection gloves on their person, and be aware of the location of personal protective equipment on the unit. Gloves must be worn on all response scenes. 4. Observers are prohibited from performing rope rescue, walking within ten (10) feet of swift moving water, and any other substantially dangerous activity. All observers must wear a life jacket within ten (10) feet of any body of water three (3) or more feet in depth.
5. Observers are not permitted to ride beyond 2300 hours (11:00 p.m.). The only exception is when you are already on a call that came in prior to 2300.
6. Observers are required to be at the designated station at their scheduled time.
7. All observers will be returned to the station at the completion of the Ride-a-long assignment or at any time requested by the participant when reasonable.
8. Audio recorders or cameras, video and still, are not permitted unless prior approval has been obtained.
At no point may pictures be taken on emergency events, or of a patient or patient identifying information.
9. Participants shall not be permitted to carry a weapon while participating in the program.
10. It is desirable to ask questions regarding procedures and activities; however, it must be done at an appropriate time. Observers shall not interfere with the EMT’s/Paramedic’s activities or duties.
11. Observers shall not participate in any activity unless specifically directed by the crewmember.
12. All observers will be required to wear a company observer identification name tag at all times during the tour.
13. Remember, a Ride-a-long participant rides in the capacity of an observer only and is under complete control of the EMT/AEMT/Paramedic at all times. Failure to follow these rules and/or the instructions of the EMT/AEMT/Paramedic will result in the immediate termination of the tour.
14. All participants for the Ride-a-long Program are expected to be dressed in keeping with the standards of Susquehanna Township EMS Inc.
15. Crews have the right to cancel the tour if the ride-a-long is disruptive or fails to follow directions.
16. Participants will wear the following: • Gray, black, navy blue dress shirt or polo shirt. • Blue or black slacks. • Brown or Black closed towed shoes preferably with ankle support. • (Optional) Dark hat without distracting logos or emblems. • Visible body brands or tattoos on the face or arms must be covered.
17. Unacceptable clothing: • High heals, flip-flops, tank top, skirt, tennis shoes, any clothing with bright or distracting logos, kilts or see through clothing is not acceptable.

If a participant arrives for his/her Ride-a-long and is not properly attired, they will be asked to reschedule the Ride-a-long for another day.

I ACKNOWLEDGE, HAVE READ, AND UNDERSTAND THE RULES AND REGULATIONS OF THE RIDEALONG PROGRAM.

Applicant Signature*

Type your Name in this Field, if you have read and agree to follow and adhere to all aspects of the provide Liability and Indemnity Release and Observer Rules and Regulation.

Parent or Guardian Consent

Parent or Guardians Name*

First Last

Parent or Guardians Phone Number*

Parent or Guardian Consent Signature*

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Observers

Observer Application

Parent or Guardian Consent