Nightingale ride-along application

All fields must be completed in order for application to go through.

Application date

Name

Phone

Is it okay for the flight crew to text you at this number?

YesNo

Years experience as an RN or EMS provider

Current EMS/Fire agency or Hospital affiliation

Years of affiliation

Title

Current supervisor

Work phone

Work email

Present weight fully clothed (lbs):

Height

Your Ride-Along will be scheduled Monday-Friday 0700hrs. to 1700 hrs. Please list your first 3 choices (Day and Time) that you are available for a Ride-Along.

Do you have any physical limitations, or medical history that could affect your experience? If so, please list:

Briefly explain your interest in our Ride-Along Program and what you expect to gain from your experience.

After your submission is received, someone from the flight crew will contact you. If no one contacts you within 14 days, please email the Team Coordinator at lmbuntin@sentara.com.