Instructions

Before filling out the form below, please read the OSF Life Flight Ride information sheet.

You will be required to print and bring the completed Consent and Release and HIPAA PR Authorization forms to your scheduld appointment.

Participant Information

* indicates a required field.

Name: *

Email: *

Phone: *

Address 1: *

Address 2:

City: *

State: *

Zip Code: *

Approximate Weight: *

Emergency Medical Service or Hospital Affiliation: *

Name: *

Relationship: *

Home Phone:

Work Phone:

Cell Phone:

Are you current on all vaccinations? *

What is the date of your last TB test? *

Have you been vaccinated for hepatitis? *

Have you participated in the OSF Ride-Along Program before? *

Are you actively involved in setting up landing zones for helicopter transport services? *

Briefly tell us your goals for participating in our ride-along program. *

We respect and safeguard your privacy. This form is secure.