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2. In consideration of the Town of Christiansburg allowing me to participate in an intern/observation program at Christiansburg Rescue, I do hereby for myself, my heirs, executors, administrators and assigns, forever release and discharge the Town of Christiansburg and Christiansburg Rescue, their officers, employees, and agents of and from any and all claims, demands, actions, cause of action, and suits at law or in equity for or on account of any accident, injuries, disabilities, physical and mental disease, death, property damage and all losses and expenses of any nature whatsoever that may be sustained by me as a result of my participation in the aforesaid program. It is my intention that this release shall, and the same hereby does fully and completely settle, satisfy and discharge all claims, demands, actions, causes of action, and rights of every nature and description against the Town of Christiansburg and Christiansburg Rescue, their officers, employees and agents, arising from my participation in the aforesaid program. I understand that I may be exposed to confidential information such as a patient’s medical or social history or other private information. I agree that I will keep all such information confidential and will not divulge it to anyone without the expressed written consent of the Christiansburg Rescue HIPAA Compliance Officer. I am forbidden from making any social media posts regarding any aspect of any incident. I further understand that state and federal regulations protect patient privacy and that Christiansburg Rescue will cooperate fully with any regulatory or law enforcement agency investigating potential violations of patient privacy regulations. The unauthorized dissemination by me of any information obtained through participation in the Christiansburg Rescue intern/observation program may subject me to criminal prosecution or civil action.
4. Observer Name*
6. Telephone*
8. Email*
10. Date of Birth*
    Date of Birth
12. Reason for the request*
    -- Select One --Prospective MemberEMS Student Clinical TimeOther
14. If other, please specify reason for request:
16. By checking this box, I authorize Christiansburg Rescue to conduct any background check necessary, including criminal/driving history, to determine my eligibility to participate in the program.*

    1. I authorize any background check necessary.
18. You will be contacted if you are selected to participate in an intern or observation program. (If observer is under the age of 18, this form must be filled out at the Rescue station by both the observer and a legal parent/guardian.)
Leave This Blank:


20. 1. Receive an email copy of this form.
21. Email address

    This field is not part of the form submission.

22. Submit

* indicates a required field