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1. Requester's Information This section is complete This section is incomplete
2. Ride-Along Request Information This section is complete This section is incomplete
3. Hold Harmless Information and Electronic Signature This section is complete This section is incomplete

Requester's Information

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
Kinston Fire and Rescue Ride-Along Program Request Form
Requester Information
Date of Application:*
Name of Requester:*
Middle Name:
Last Name:*
Address:*
City:*
State:*
Zip Code:*
Contact Phone Number:*
Email Address:*
How did you hear about the Kinston Department of Fire and Rescue Ride-Along Program?*
1. Fire Personnel
2. Fire and Rescue Website
3. Other
If other, please Explain:
Why do you want to participate in the Ride-Along Program*
1. Want to find out about Fire and Rescue
2. Want to become a Kinston Firefighter
3. Want to see what my friend/relative does
4. Other
If other, please Explain
Have you ever been Convicted of a Crime?*
1. Yes
1. No
If Yes, please Explain in full:
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Hold Harmless Information and Electronic Signature

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 permission 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 purposes. I understand that I may be injured as a result of accompanying a Firefighter in performing his/her duties. I understand that the Firefighters 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 unless 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 Chief during my ride. I hereby 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.
Date and time of the Waiver of Hold Harmless and Release:*
Date and time of the Waiver of Hold Harmless and Release:
Date and time of the Waiver of Hold Harmless and Release:
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.
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.
1. I agree.
Electronic Signature*

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Kinston Fire and Rescue Ride-Along Program Request Form

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Requester's Information

Ride-Along Request Information

Hold Harmless Information and Electronic Signature

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