Application

Subject (*)

Are 18 years of age or older? (*)

Yes

No

Full Name (*)

Address (*)

City (*)

State (*)

Zip (*)

Phone (*)

Alt Phone

Email: (please note, HEM uses email extensively via YAHOO!Groups & Facebook): (*)

Can you receive text messages at this phone# ? (*)

Yes

No

How did you hear about HEM? (*)

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Briefly, what is your experience with concerts and large events? (*)

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Certifications (*)

Medical and Crisis experience and education, please list job position titles if applicable. (*)

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Are you trained and able to follow HIPAA? (*)

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Please write the names, phone numbers and contacts of three references that are not relatives. Include any current HEM members that you know: (*)

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Desired Username for website (*)

Password (*)

Have you ever been convicted of a felony? If so, please describe: (*)

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HEM Would like your permission to use a facebook or other images as part of your "member file" in order to help identify you. Are you Ok with this? If not you must submit a photo to HEM (*)

Yes

No

I will submit my own image

You have reviewed the HEM Orientation, all safety policies, protocol procedures, behavior and conduct expectations as described in the HEM Documents and Terms of Service found in the HEM Resources tab, on the HEM website. (*)

Yes

No

Type Your Initials Here - This Confirms that you have read and agree to all the information stated above (*)

Send a copy of this message to yourself