Student Ride Along Form

Student Rider Form

MedEx Release and Ride-Along Directive

*Please Read*

Date(Required)

Student Name(Required)

First Last

Phone (Optional)

Email(Required)

Emergency Contact(Required)

Name

Contact Info(Required)

Phone or email

School Informaton(Required)

EMS Program

Chicago EMT Training

First Five

Weiss

St. Francis

Malcom X College - City College of Chicago

Other

Expected Graduation Date

MedEx 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 form

Max. file size: 50 MB.