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Please complete the following form for the ride along program and return it to the Williamsport Bureau of Fire office at least two (2) weeks in advance before the date you wish to ride along.
The fire chief will then review the application and you will be contacted to confirm the date and time of the ride-along. If you should have any questions, please contact Renee Smith at (570) 327-1602, Monday through Friday from 8:00 am - 4:00 pm.
Know all men by these presence, that I ____________ on my behalf and for my heirs, next of kin, executors, administrators, estate agents and assigns, and representatives of any nature at all, for and in consideration of the authorization and permission to accompany fire fighters or any fire fighter of the Wlliamsport Bureau of Fire during the course of their duties, which have been granted to at my voluntary request, after having been advised of the potential hazards of activity, do hereby waive and release all demands, damages, actions, cause of action, suits and claims of any nature at all, whether in law or in equity, or my heirs, next of kin, executors, administrators, estate, agents and assigns, and my representatives of any nature whatsoever might otherwise have against the city of Williamsport, Bureau of Fire, and every fire fighter and his and her heirs, next of kin, executors, administrators, and estate, on account of my death or injuries, both to person and to property while engaged in this activity.
Further, I hereby agree to indemnify and hold harmless the of Williamsport, the Williamsport Bureau of Fire and its individual firefighters, their heirs, next of kin, executors, administrators, successors and assigns, from all liability, cost, and expenses arising out of injury or damage suffered by as a result of accompanying a firefighter of Williamsport Bureau of Fire, as set forth herein.
It is expressly agreed and understood that this waiver and release shall apply for the express purpose of precluding forever all claims, suits, demands, damages, and cause of action that I or my heirs, next of kin executors, administrators, estate, agents, assigns and representatives of any nature whatsoever might otherwise assert against any of the aforesaid parties as a result of my association and activities with Williamsport Bureau of Fire.
I hereby declare that the terms of this waiver and release have been fully read and understood by me, and I hereby acknowledge receipt of a copy of this agreement. In further consideration of the aforesaid, authorization and permission granted to me to accompany a firefighter or firefighters of the Williamsport Bureau of Fire, at my own request, I hereby promise and agree to fully comply with all instructions given to me for purpose of protecting my personal safety and that of my property.
Applicant Signature:
Name of Business/School/Fire Company Being Represented *
First Name *
Last Name *
Address *
City *
State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip *
Phone *
Email *
Date of Birth *
Please indicate below, the date and time you would like to ride. Ride along hours are between 8:00 am - 6:00 pm. No nighttime ride alongs are permitted.
Ride Along Date/Time *
Insurance Information: Include names of all companies and policy numbers OR attach a copy of insurance cards:
Add File
Include a brief statement on why you would like to “Ride Along” and how it would benefit you in the future:
There is a minimum age of 16 to participate in this ride along program if not affiliated with any fire department or first responder agency.
If you are a junior firefighter or affiliation, you must include a letter from your fire chief indicating that you will be covered under their insurance.
If you are affiliated with any school mentoring program you must attach all necessary paperwork from the school outlining you're course requirements and the school must provide a letter indicating that you will be covered under their insurance.
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