Falck Waiver Bay Area – Emergency Medical Services University, LLC

Please Download and Read a Copy of this packet for FALCK so that you are aware of the reqruiements for completing your externship.

Failure to abide by the guidelines may result in removal from the externship site and may be considered a violation of the Student Code of Conduct.

By signing and submitting this form, you consent to an electronic signature and acknowledge that your electronic signature is legally binding. You confirm you have read and agree to the waiver terms displayed above.

Required Personal Information

Student ID *

Found in your email. (Example 99999FT-01)

ID Birth Parent/Guardian

Date *

Phone *

Email Address *

Residence Address *

Address Line 1

Address Line 2

City

State

Zip Code

Reason for Ride-Along *

Career Exploration
EMT Student/Paramedic Student

Emergency Contact Information

Emergency Contact Name *

First

Last

Relationship *

Emergency Contact Phone *

Emergency Contact Email Address *

Ride-Along Request Information

NOTE: THESE DATES MUST MATCH WHAT YOU PUT ON THE EXTERNSHIP REQUEST FORM OR THE DATES WILL BE REJECTED

Externship Date Request 1 *

Externship Date Request 2 *

Externship Date Request 3 *

Externship Date Request 4 *

Externship Date Request 5 *

Preferred Stations *

Hayward
Livermore
Oakland

Day or Night Shifts *

Verification Section

Verification Document

Verification Document Number *

For Example: Driver's License Number

Date of Birth *

File Upload *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Participant Initials *

Name *

First

Last

Parent/Guardian Section

Parent or Guardian Signatures are required if the student is under 18 years of age at the time of signing this form.

Parent/Guardian Name (Print)

Relationship to Minor

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