Student Rider Form MedEx Release and Ride-Along Directive*Please Read* Consent (THE UNDERSIGNED HAVING READ THIS RELEASE AND KNOWS AND FULLY UNDERSTANDS THE CONTENTS THEREOF)(Required) I agree to the MedEx Ride Along policy.Date(Required) Student Name(Required) First Last Phone (Optional)Email(Required) Emergency Contact(Required)NameContact Info(Required)Phone or emailSchool Informaton(Required)EMS Program Chicago EMT Training First Five Weiss St. Francis Malcom X College - City College of Chicago Other Expected Graduation DateMedEx Preceptor Information(Required) MedEx Crew Names Rig # Hello!Please let us know what's on your mind. Have a question for us? Ask away.Photo ID(Required)Please take a photo of your driver's license or identification card and upload with this formMax. file size: 128 MB.
