*Name:

Base Requested:

*Dept./Hospital:

    ROTOR:

Select One No Preference MF 1 - Columbus MF 2 - Allen Center MF 3 - Wellston MF 4 - Coshocton MF 5 - Lodi MF 8 - New Philadelphia

*E-Mail Address:

    MICU:

Select One No Preference MF 11/12 - Columbus MF 15 - Marion MF 16 - Wooster MF 19 - Cleveland

*Address:

*Contact Phone
 (w/ area code):

Address Cont.:

*Phone Type :

Select One Home Work Cell

*City:

*State:

*Training Level:

  Select One Firefighter EMT RN MD/DO Dispatch Police Other (Please specify)

*Zip:

*Affiliation:

Select One EMS/FIRE HOSPITAL LAW ENFORCEMENT OTHER (Please specify)

Have you ridden with MedFlight in the past 12 months?  Select One Yes No

*Weight:

Are you related to a MedFlight partner?  If so, who? 

Additional Information (Please provide three dates you are available. NOTE: Requests must be no sooner than one week from the date of this request):

If you do not have an e-mail address, please contact Shane Mattingly at (614) 204-4658.