SPECIAL EVENTS DIVISION APPLICATION - 1st Response Medical Services

HEALTHCARE PROVIDER APPLICATION

Thank you for your interest in becoming a Healthcare Provider for 1st Response Medical Services. Below is a brief form which is for informational use only. In order to provide medical aid as a medical provider for sporting events for 1st response Medical Services. we collect minimal information PLEASE BE SURE TO READ THE TERMS OF SERVICE PRIOR TO COMPLETING and SUBMITTING THIS APPLICATION.

First Name *

Last Name *

Email Address *

Cell Phone Number *

Cell Phone Carrier/Provider *Sprint, Verizon, Boost, MetroPCS, Sprint, AT&T etc.. Whoever your Cellphone Provider is

Is there anything that would cause an Issue with you working with 1st Response Medical Services (Exp... Medical, Mental, Handicap etc....) *YesNo

If yes, please explain *

Are you over the age of 18? *YesNo

Medical Providor Questions

Are you a PA State Certified EMT, Paramedic, PHRN, or EMR? *YesNo

CERTIFICATION # *

MANDITORY QUESTIONS

DO YOU HAVE YOUR OWN VEHICLE/RELIABLE TRANSPORTATION?? *Please note that Public Transportation is not reliable transportation. Of you do not have a vehicle, you will be unable to work with us!

Do you have at Minimum, and BLS CPR Certification or Equivalent? *

Agreement

I certify that information contained in this application is true and complete. I certify that I have read, and accept the NON-COMPETE Agreement. I understand that false information may be grounds for denial of Healthcare Provider status. I also understand that as a medical professional, I am expected to operate professionally and operate according to my current medical certification level. I understand that I will not be an employee of 1st Response Medical Services Event Division, but I will be working as an Independent Contractor providing my services.

Do you agree to the 1st Response Medical Services non-compete agreement? *Yes, I agree with the 1st Response Medical Services Non-Compete Agreement.

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