Ride Along Application

Thank you for your interest in the Vanderbilt LifeFlight Ride-Along Program.

1Application > 2Forms > 3Signature Page
Service line you are applying to ride-along with. *
Name Name * First Last
Age
(Must be over the age of 18 years of age). *
Must be a number greater than or equal to 18.
Gender *

Gender Male Female
Weight (Maximum participant weight is 220 lbs.)
***All ride-along participants will be required to weigh-in on the morning of their ride-along for verification to ensure accurate information for flight***. *
Waist Size
(Must be under 44 inches) *
Must be a number less than or equal to 44.
Email *
Phone Phone * - ### - ### ####
Physical Address Physical Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Do you have a seizure disorder or other medical condition that may impact you ability to ride? *

Do you have a seizure disorder or other medical condition that may impact you ability to ride? Yes No
Employment Information
Are you a VUMC employee?
(If yes, please complete additional VUMC Manager Approval form on page 2). *
Employer / Affiliated Agency *
Department *
Title / Job Description *
Supervisor Information

Employment in emergency services or a hospital setting is required.
Supervisor Name Supervisor Name * First Last
Supervisor Title *
Supervisor Organization *
Supervisor's Email *
Supervisor's Phone Supervisor's Phone * - ### - ### ####
Ride-Along Preferences

Every effort will be made to schedule you on your preferred date at your preferred location. Please note that due to new hire orientation or other factors this may not happen.
Were you referred to the ride-along program by a LifeFlight Crew member? if so who? Were you referred to the ride-along program by a LifeFlight Crew member? if so who? First Last
Preferred Ride-Along Base *
Secondary Ride-Along Base *
Preferred Ride-Along (RAL) Day Preferred Ride-Along (RAL) Day * / MM / DD YYYY
Second Choice RAL Day Second Choice RAL Day * / MM / DD YYYY
Third Choice RAL Day Third Choice RAL Day * / MM / DD YYYY
Optional information for requested dates. Example: Available any Tuesday in September.
Maximum of 1000 characters allowed. Currently Entered: 0 characters.
Please enter your emergency contact information.

One contact is required, the second contact is optional.
Emergency Contact Emergency Contact * First Last
Emergency Contact Phone # Emergency Contact Phone # * - ### - ### ####
Emergency Contact Address Emergency Contact Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Relationship to Emergency Contact *
Emergency Contact Emergency Contact First Last
Emergency Contact Phone # Emergency Contact Phone # - ### - ### ####
Emergency Contact Address Emergency Contact Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Relationship to Emergency Contact
Maximum of 100 characters allowed. Currently Entered: 0 characters.
Goals
What do you expect to learn from your ride-along experience? *
Maximum of 200 words allowed. Currently Entered: 0 words.
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

Ride Along Application

Ride Along Application

Employment Information

Supervisor Information

Ride-Along Preferences

Please enter your emergency contact information.

Goals