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2. Today's Date*
   Today's Date
3. Information about Durham Fire Department's Ride-Along Program
   Submitting the information requested here indicates your desire to ride along with a Durham Fire Department Emergency Crew. Submission of this form does not imply confirmation or approval of the requested ride-along.
5. First & Last Name*
6. Date of Birth*
   Date of Birth
7. Email Address*
9. Current Address - Street, City, State, Zip
11. Primary Phone # (Cell)*
12. Driver's License #*
14. Emergency Contact Name*
15. Emergency Contact's Phone Number*
17. If you are requesting to ride at a specific station or with a specific person, please list that information here.
19. If you have a preference for a ride along date, please list 3 possible dates that you would like to choose for a ride-along. If you are requesting to ride along with a current employee, please check with that person in advance before scheduling a date. List date preferences here.
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23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

* indicates a required field