I have read and clearly understand the Marysville Fire District Rider Policy and my role as a participant as an Observer Rider.

I clearly understand that I could be placed in varying degrees of jeopardy by exposure to communicable diseases and blood-borne pathogens, and such contact could result in my personal health being harmfully affected. In addition, I understand that communicable diseases that I might encounter could be transmitted by me to my family and friends.

I clearly understand that due to the nature of emergency responses by Emergency Medical Services to medical/trauma scenes, the ambulance is operating in an emergency mode that could enhance the possibility of a vehicular accident; thus, endangering my life and/or physical well-being.

I clearly understand that due to the varying types of calls in which the ambulance responds, I could be endangering my physical and/or mental well-being and/or life by hostile/violent patients, dangerous scenes such as downed electrical wires, hostile crowds, exposure to traffic, etc., as well as psychological impairment due to abnormally gross injury, death scenarios, and such.

I declare that I have read the above waiver, and I voluntarily assume all of the risks and accept total personal responsibility for the above-stated hazards and the other unmentioned and unforeseen hazards that are related to this type of work. Further, I agree to defend, indemnify, and hold the Marysville Fire District, its Board of Directors and Officers, its employees and its medical staff, harmless from and against any and all claims, demands, liabilities, damages, and expense, including attorney’s fees and other legal costs, for injury and/or illness to myself or my family, caused, or asserted to have been caused, by my personal choice to participate as Observer Rider or Student Rider with the Marysville Fire District including any future claim or suits brought by, or on my behalf of myself, or family and friends.

I declare that I am eighteen (18) years of age or older.

I attest that all written and verbal information provided to the Marysville Fire District is valid and correct in nature.

DO NOT SIGN IF YOU DO NOT CLEARLY UNDERSTAND THIS WAIVER.

I understand and agree that in the performance as an Observer Rider with the Marysville Fire District, I must hold patient information and identity in complete confidence. Furthermore, I understand that violation of the confidentiality policy of the Marysville Fire District may result in my Rider privileges being revoked. I also understand that civil and criminal penalties are permitted under the law if I breach confidentiality of any patient identity or other patient information.

I acknowledge that patients provide, and Marysville Fire District collects, personal and confidential information verbally, in writing, and through digital means. I understand and agree that any information pertaining to patients is strictly confidential and protected by federal and state laws, and that I will not use or disclose patient information in any way, unless Marysville Fire District authorizes me to do so.

I agree that I will comply with all HIPAA policies and procedures in place at Marysville Fire District during my experience as a guest/trainee. If at any time I knowingly or inadvertently breach patient confidentiality or violate the HIPAA policies and procedures of Marysville Fire District, I agree to notify Marysville Fire District immediately.

I also understand that I may be exposed to other confidential or proprietary information of Marysville Fire District and agree not to reveal any of that information to anyone at any time, unless I am authorized by Marysville Fire District to do so. This means that I will not disclose information about Marysville Fire District’s business practices or other information that Marysville Fire District might consider to be confidential or proprietary.

Failure to uphold these obligations may result in immediate suspension or termination of the privilege to gain clinical experience or observe the activities of Marysville Fire District. Upon termination of the privilege for any reason, or at any time upon request, I agree to return any and all patient information or confidential or proprietary information in my possession. I understand that any patient or confidential information that I see or hear while a guest/rider will stay here at Marysville Fire District when I leave.

I have been given an overview of Marysville Fire District’s HIPAA policies and procedures and have been given access to review those policies and I agree to abide by them