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Kinston Fire and Rescue Ride-Along Program Request Form

  1. Kinston Department of Fire and Rescue Seal

  2. Kinston Department of Fire and Rescue

    P. O. Drawer 339, 401 E Vernon Avenue Kinston, North Carolina 28502 Office Phone: 252-939-3164 Fax Phone : 252-939-3157

  3. Kinston Fire and Rescue Ride-Along Program Request Form

  4. Requester Information

  5. How did you hear about the Kinston Department of Fire and Rescue Ride-Along Program?*

  6. Why do you want to participate in the Ride-Along Program*

  7. Are you related to an Employee of the Kinston Department of Fire and Rescue?*

  8. Have you ever been Convicted of a Crime?*

  9. Information of Ride-Along Requested

  10. Length of Ride-Along:*

  11. Preferred Fire Company and Shift to Ride-Along with:

  12. Waiver of Hold Harmless and Release:

    In order to protect and ensure the safety of the officers, I give the Kinston Department of Fire and Rescue my perimssion to have a Criminal Background Check completed on me. I the UNDERSIGNED have requested and received permission from the Kinston Department of Fire and Rescue, to accompany a Firefighter in his/her daily activities, including riding in vehicles assigned to them for duty perposes. I understand that I may be injured as a result of accompanying a Firefighter in performing his/her duties. I understand that the Firefighter's may have to drive at high speeds. I agree that if I suffer any injury as a result of my participation and presence in this "Ride-Along Program", I will make no claim against the Kinston Department of Fire and Rescue, The City of Kinston or any of its employees. I expressly assume the risk of any injury. I further agree to remain in the vehicle at all times uless expressly directed by the Fire Department Personnel to exit the vehicle. I will obey ALL Directions given by that person and/or Company Officer and/or Battalion Commander during my ride. I hearby waive all rights that may arise from any injury or other damage that might be suffered as a result of, or while accompanying the Firefighter of the Kinston Department of Fire and Rescue in the performance of his/her duties.

  13. This Waiver of Hold Harmless and Release has been read, agreed to and will be kept by me starting at this date and time that it was read and understood.

  14. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  15. Leave This Blank:

  16. This field is not part of the form submission.