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Kinston Fire and Rescue Ride-Along Program Request Form

  1. Kinston Department of Fire and Rescue Seal

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

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

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

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

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

  7. Length of Ride-Along:*

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

  9. 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.

  10. This Waiver of Hold Harmless and Release has been read, agreed to and exicuted by me this day and time.

  11. 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.

  12. Leave This Blank:

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