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.

I have read and agree to the ride along requirements. (This box must be selected or your request will not be considered)

General Information

Name

Address

City

State

Zip Code

Cell Phone

Home Phone

Phone - Work

Email Address

Age

Weight

Organization/Agency

Organization/Agency Name

Certification/License

Please provide three possible fly dates.

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