Ride-Along Observer Program Release Form Page 3
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3General Order l-3, Release
Page 3
6.
If I have been denied membership in another fire/rescue organization outside of Prince
George's County, said reason(s) will be disclosed upon request to the Prince George's
County Fire Department's authorized representative.
7.
Should I be a bona fide member of a fire and/or rescue association or department, I will
disclose the name of such organization:
________________________________________________________________________
Name of Organization:
________________________________________________________________________
Address
_____________________
__________________________________________
Telephone
President/Chief Officer
8.
Upon request, a medical waiver statement from a physician must be submitted to
substantiate fitness to perform in a ride-along observer status on-the-scene of emergency
operations.
This release form shall become a permanent record of the Prince George's County Fire
Department.
Expected "Ride-Along Observer" dates:
___________________________________ to ______________________________
At the end of this period, a new release form must he obtained.
_______________________________________
____________________________________
Signature
Printed Name of Participant
______________________________________________________________________________
Address
________________________
__________________________
__________________
Home Telephone
Work Telephone
Date of Birth
______________________________________________________________________________
Name of Witness (Line Officer/Administrative Officer of PGFD)
__________________________________
Officer (Rank)
Date
Approved by (choose one)
________________________
_____________________________
Volunteer Chief
Departmental Duty Officer
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