First Name*:	Middle Name:	Last Name*:
CPU Box #*:	Class*: 2013 2014 2015 2016 2017 2018 2019 Other	Local Phone Number*:
E-mail Address*:	Building*: Other Alpha Delta Phi Anderson Tower Burton Chambers Crosby DeKiewiet Delta Kappa Epsilon Drama House Fairchild Gale Gilbert Goler House Hoeing Kendrick Lovejoy Medieval House Munro Psi Upsilon Riverview Sigma Alpha Mu Sigma Chi Slater Susan B. Anthony Theta Chi Tiernan Towne House University Park Valentine Whipple Park Wilder Tower	UR Room Number:
Perm. Address*:	Address 2:	City*:
State*: Other Alabama Alaska Arizona Arkansas Connecticut California Colorado Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Mighigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming	Zip Code*:	Home Phone Number*:
Date of Birth*: 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 0 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013	LC Code (2 digits on lower left corner of URID)*:	UR Student Number*:
Gender*: Female Male	Cell Phone Number:	Pager Number:

Medical History

Please List All Allergies (including Latex):

Please List Medical Problems (eg. Diabetes):

Do you have any physical or mental disabilities and/or limitations which may in any way restrict your service to this organization? :
Yes No

List any serious illnesses, operations, or injuries you have had within the last five (5) years:

Do you wear corrective lenses? :
Yes No

Driver Status & Conviction Record

Driver's License:

ID#:

State: Other Alabama Alaska Arizona Arkansas Connecticut California Colorado Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Mighigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming

Have you had any moving violations in the last 18 months? :
Yes No
Have you had any chargeable accidents in the last 3 years? :
Yes No
Have you ever been convicted of DUI, DWI, or DWAI? :
Yes No
Have you had any criminal convictions in the last 5 years? :
Yes No

If YES, please explain

Emergency Care Training Status

Do you have any previous experience with an ambulance service? :
Yes No

If YES, please explain

Do you have any previous health related work experience? :
Yes No

If YES, please explain

CPR Type:
None ARC CPR-FPR (1 yr) AHA BLS-HCP (2 yrs)

CPR Expiration Date(If you have it):
0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 0 2009 2010 2011 2012 2013 2014 2015 2016 2017

Do you have First Aid Certification? :
Yes No

Highest New York Certification

New York Certification: None CFR Basic Intermediate Critical Care Paramedic

Cert Number:

Expiration Dates: 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 0 2011 2012 2013 2014 2015 2016 2017 2018

Highest State Certification (if other than NY)

Certification State: Other Alabama Alaska Arizona Arkansas Connecticut California Colorado Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Mighigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming

State Certification: None CFR Basic Intermediate Advanced Paramedic

State Cert Number:

Expiration Date: 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 0 2011 2012 2013 2014 2015 2016 2017 2018

Highest National Registry Certification

Nrcert: None CFR Basic Intermediate Paramedic

Cert Number:

Expiration Dates: 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 0 2011 2012 2013 2014 2015 2016 2017 2018

**Please make copies of all certification cards and submit them to the secretary**

References(not related to you)

Name*:	Telephone*:
Name*:	Telephone*:

Please list any special interest or other activities you are involved with:

Please list any MERT members with whom you are acqainted:

Emergency Contacts

Name*:	Telephone*:
Name*:	Telephone*:

Please explain why you are interested in becoming a member of R/C MERT*:

Please include any other information which you feel is pertinent, and would like R/C MERT to know:

Password (8-16 characters)*:

Re-type Password*:

I hereby state that all of the above questions have been answered truthfully and without gross omission, and I authorize the University of Rochester River Campus MERT to check any or all of the above statements with the proper law enforcement agency. I also understand that the willful falsification of, or omission from, this application will subject it to immediate rejection. It is further understood that this application will be handled in accordance with the Civil Rights Act of 1964, and no discrimintation will occur due to sex, religion, race, creed, national origin, or sexual orienation. All information in this application is considered confidential and will only be reviewed by the Executive Board of the River Campus MERT. Any applicant under the age of 18 years must also have their parent/guardian sign this application, or submit a signed statement of parental permission with this application.