-- Demographic Information --
Name (First and Last): 
City: State: Zip: 
EMail: Reenter EMail Address:   Cell Phone: 
Home Phone:Weight: Age:  
*200 lb weight limit for observers at helicopter bases**18 Years Min*
ID Info: ID No:   ID State:  
-- Emergency Contact Information --
Relationship: Home Phone:
Work Phone:Cell Phone: 
City: State: Zip: 
-- Agency and Training Information --
City: State: Zip: 
Your job title at this agency: 
Work Phone:Fax Number:
Affiliation Training Level: 
Lic #: Lic # Lookup:EMSNurse
Has Observer Ridden in past 12 months: 
What do you expect to learn from your ride along experience:
-- Location And Base Information --
Base Type:

Select Date (only dates with a blue background are currently available):
<April 2018>
-- Legal Information --
I, and my heirs and assigns, release and indemnify Ohio Medical Transportation, Inc. dba MedFlight of Ohio, from any and all liability or claims for injury, illness, damages or death which may occur as a result of my observation experience. I recognize that this observation experience is solely voluntary on my part, and that I will not participate in providing any direct patient care unless specifically directed by the medical crew. I assume full responsibility for any risk that may occur on the helicopter or Mobile Intensive Care Unit and fully understand that MedFlight of Ohio is unable to predict or guarantee that travel by MICU or helicopter is free of hazards. I agree to abide by MedFlight’s weapons-free policy and hazardous material prohibitions. I agree any patient contact or information obtained as part of my observation is strictly confidential in compliance with HIPAA, and I will not disclose or share any information obtained. I verify I hold a valid license/certification in the field named above, and that I am actively affiliated with the agency or school so named. I further state that all information listed above is accurate and true.
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