Vidant Medical Transport iRide Program Application

Please complete all fields. Incomplete applications will not be processed.

Be sure to include your correct email address, as this is the primary method of communication for iRide.

 

Personal Information: 

First Name     Middle Initial      Last Name  

Date of Birth (mm/dd/yyyy)   

Street Address  

City      State      ZIP Code     Country  

Telephone (home)      Telephone (cell)  

Email Address      Check here if you are a Vidant employee  

 

Vehicle Information (required for Vidant Parking Enforcement):

Vehicle Make      Vehicle Model      License Plate #  

Emergency Contact Name     Relationship  

Telephone (home)      Telephone (cell)  

 

 Professional Information: 

Please check your level of certification/licensure:

EMT         Paramedic         Fire Fighter         911 dispatcher  

Law Enforcement Officer         RN         Other public safety personnel  

Brody School of Medicine EM Resident  

Current Employer/Volunteer Agency  

Please provide a reference contact from this employer/volunteer agency:

Name      Title  

Telephone  

 

Medical History (please check all that apply):

Seizure Disorder         Respiratory Disease  

Diabetes         Ear/Sinus Disorders  

Heart Disease         Pregnant?  

Allergies (please list)  

Current Medications, including regularly taken over the counter meds (please list)  

Current Weight    (Must be under 200 lbs. Weight will be verified for air rotation.)

 

iRide Preference (mode/location):

For Air (check one): 

Greenville         New Bern         Elm City  

For Ground (check one): 

Greenville         Halifax         Windsor         

Beulaville         New Bern         Jacksonville  

 

Objectives for iRide: 

Please tell us  more about why you would like to complete the iRide Program with our transport team. This will allow us to better tailor your iRide experience to meet your specific needs. Please list any area of special interest that you would like to see while you are with us. We will make every effort to accommodate you.