Prefix Please Select a PrefixAMBULANCE COMMANDERASSISTANT CHIEFBATTALION CHIEFCAPTAINDRIVER ENGINEERFIRE CHIEFFIRE PARAMEDICFIRE PARAMEDIC CANDIDATEFIREFIGHTERLIEUTENANTMR.MRS.MS.PARAMEDIC FIELD CHIEFPARAMEDIC IN CHARGE

First Name:

Last Name:

Gender Please Select a GenderFEMALEMALE

Department Name

Email Address

Street Address

City

State Please Select a StateALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREFLORIDAGEORGIAHAWAIIIDAHOILLINOIS INDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIARHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING

Zip Code

Primary Phone Number

Secondary Phone Number

In your own words, tell us why a Peer Support Team like ours is needed.

Please tell us why you would like to join our team.

Can you commit to maintaining confidentiality with those you may be assisting?
Yes
No

Do you have any behavioral health experience and/or training that could benefit firefighters and first responders?
Yes
No

Are you able to respond while on duty?
Yes
No

Are you able to respond while off duty?
Yes
No

Are you willing to respond during the night time hours?
Yes
No

Are you willing to teach the classes we provide?
Yes
No

Do you have Fire Instructor I or Fire and Life Safety Educator certification?
Yes
No