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ABOUT
EVENTS
Careers
Apply
Contact
SPECIAL EVENTS DIVISION APPLICATION
911 EMS Providor for Conway, PA in Beaver County
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
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Last Name
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Email Address
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Cell Phone Number
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Cell Phone Carrier/Provider
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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....)
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Yes
No
If yes, please explain
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Are you over the age of 18?
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Yes
No
Medical Providor Questions
Are you a PA State Certified EMT, Paramedic, PHRN, or EMR?
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Yes
No
What is your Professional Provider level?
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EMT
AEMT
PARAMEDIC
PHRN
RN
LPN
EMR
PA
ATHLETIC TRAINER
PHYSICIAN
certification level
CERTIFICATION #
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MANDITORY QUESTIONS
DO YOU HAVE YOUR OWN VEHICLE/RELIABLE TRANSPORTATION??
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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?
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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?
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Yes, I agree with the 1st Response Medical Services Non-Compete Agreement.
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