LifeFlight

This program is limited to Hospital personnel that work in Critical Care areas (ICU, CCU, Emergency, etc) or Public Safety personnel.  Nursing students must be in the last quarter of their school curriculum (last year of a 4 year program, last 6 months of a 2 year program). All applicants must be at least 18 yrs old, 6′ 3″ or less, and 200 lbs or less. PLEASE READ EACH QUESTION CAREFULLY BEFORE YOU ANSWER.

First Name: Last Name:

All applicants must be 18 or older. Are you at least 18 years old? ---- Yes No

All applicants must be 6′ 3″ or less. Height:

All applicants must be 200# or less. Weight:

Service, Department, School, or Hospital Affiliation:

Certification: (Check all that apply) If student check “Other” and place type (nursing, paramedic, etc) in “Other Description”

First Responder: EMT: EMT-P: RN:

MD: Fire Fighter: Police Officer:

Other:

Other Description:

Phone Number (cell phone preferred):

Email Address:

May we add you to LifeFlights email list: ---- Yes No

Preferred Base Site: -------- Boquet Airport (Jeanette) Butler Airport Cannonsburg Hospital Indiana Hospital Rostraver Airport

Briefly explain what you hope to gain from your experience with LifeFlight:

Provide 3 dates that are good for you, with the closest date a MINIMUM of 7 days from today. Please assure that the dates you submit as available will not change as it is very difficult to reschedule them. (The extern program is available every day between the hours of 9 a.m. and 5 p.m.):

Do you have any significant medical condition(s) that might interfere with your ability to fly with us?

---- Yes No

If "Yes", please explain:

It may take up to 1 week to confirm your request. Please assure that the dates you are requesting are more than 1 week from today. Once scheduled, you will receive a confirmation via e-mail. It will contain all of the information that you need for your observer shift.