HomeMy WebLinkAboutApplication to observe
Please read the attached policy prior to completing application to ensure eligibility.
Instructions: This form must be completed, including the Police record search, at least three working days prior to
your requested date. Upon completion, please give this form to the Fire Department secretary. It is your
responsibility to contact the on-duty Captain at 356-5261 to schedule your participation in the ride-along
program.
Name: Birthdate:
Address: SSN#:
Telephone #: (During normal business hours)
This form must be stamped by the Iowa City Police Department Records Division prior to its approval to ensure
that the applicant has no arrest record that would preclude participation in this activity.
FOR ICPD RECORDS USE ONLY
Dates requested to ride: First Choice: Alternate: Alternate:
Apparatus preference? Shift preference?
Reason for participation:
List any background in Emergency Services or related activities:
Policy exceptions requested and explanation:
(complete both sides) Appendix No. GP-044-001
IOWA CITY FIRE DEPARTMENT
Application to Observe
That I, the undersigned , a private person, for and in consideration of the
privilege of riding as a voluntary observer in a Fire Department vehicle of the City of Iowa City, Iowa, recognize and fully
understand that Fire Department activity involves inherent dangers and risk of injury, including death, do hereby agree to
assume all risks, both foreseen and unforeseen, attendant to such Fire Department activity, including motor vehicle accidents
on either public streets or private property, and do hereby release and hold harmless the City of Iowa City, the Iowa City Fire
Department, its agents and employees, in both their public and private capacities, from any and all liability, claims, suits,
demands, or causes of actions which may arise from riding as a voluntary observer on a Fire Department vehicle including
injury or death which may result or be caused by another person while responding to a Fire Department call.
Furthermore, due to the nature and type of information disclosed to Fire Department personnel during the course of
emergency response, voluntary observers may be privy to information and material which is legally private, confidential,
and/or restricted from public disclosure. Such information includes personally identifiable health information (PHI), such as
diagnosis, symptoms, manifestations, and any other medical information disclosed to Fire Department personnel in the course
of their response. Voluntary observers agree not to disclose, discuss, or make available, either directly or indirectly, any such
non-public information gained as an observer. Failure to follow this directive may result in legal action governed by the laws
of the State of Iowa. Voluntary observers further acknowledge that any civil or criminal liability for such dissemination shall
be the sole responsibility of the voluntary observer, and not subject to indemnification and/or defense by the City.
I have read and agree to the above-stated terms.
Signed this day of , 20
Name:
Address:
Phone:
Signature:
(For Office Use Only)
Fire Chief/Officer-in-Charge:
Policy Exceptions/Comments:
Ride Schedule (Date):
1st Ride Time 2nd Ride Time 3rd Ride Time 4th Ride Time
(complete both sides)
IOWA CITY FIRE DEPARTMENT
Release, Waiver of Liability and Confidentiality Agreement
For persons under the age of 18: Parent Guardian
Signature: