Life Lion Ride Along Request Form

Please read the guidelines and expectations first and then submit the completed form.
By selecting the box below you are electronically signing & agreeing to adhere to all of our guidelines & expectations including the Hershey Medical Center Confidentiality Agreement, Code of Ethical Behavior, and Personal Appearance Policy.
General Information

Please provide three possible fly dates.

Please enter the characters you see in this picture:


This helps prevent automated form submissions. If you are not sure what the characters are, make your best guess. You will have another try in the next screen.
Can't see the image? Click here for an audible version in English.