Ride-Along Request

Thank you for considering Tri-State Ambulance or Tri-State Regional Ambulance for an ambulance ride along. Please complete the below form to inquire further. As part of this request, please download the the Release for Ride-Along Program at the link below, complete it, and bring it with you to your scheduled ride along.

Release for Ride-Along Program

Please select the company you are requesting to ride along with. *

Your Name *

Your Email *

Confirm Email

Phone Number *

Emergency Contact Name *

Relationship to Emergency Contact *

Emergency Contact Phone Number *

Job Title / Status *

Other Job Title / Status

If you chose other, please describe.

Have you completed a ride along with TSA or TSRA before? *

How did you hear about the ride along program? *

What are your goals for participating in a ride along? *

Please list a few dates you are available. Dates must be 3-6 weeks from today. Shifts are typically 12 hours and start times range from 5:00 AM to 10:00 AM. *

Message

Release for Ride-Along Program

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