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Volunteer Member
Mount Sinai
,
New York
,
United States
| Operations
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Application Form
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First Name *
Last Name *
Email *
Date of Birth *
Home Phone Number
Cell Phone *
Cell Service Provider *
Home Address *
Local Address (if student)
What is the name of your emergency contact? *
What is the relation of your emergency contact? *
What is the phone number of your emergency contact? *
How did you hear about Port Jefferson EMS? *
Are you currently a certified EMT or Paramedic? *
Yes
No
Do you have a valid drivers license? *
Yes
No
Did you attend an information session at our headquarters? If yes, what date? *
Are you a student? *
Yes
No
If you are a student, what year in school are you? *
--Select--
Freshman
Sophomore
Junior
Senior
Post Grad
N/A
Have you ever applied to Port Jefferson EMS before? *
Yes
No
Have you ever been a member of a Fire/EMS agency before? *
Yes
No
How did you hear about us? *
--Select--
Website
Social Media
A current member
Event
Other
Tell us about yourself in a 100 words or less? *
What is a good time to contact you via telephone? *
Resume
Thanks for your time
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