Support LifeFlight Education and Patient Programs
Applicants must be at least 18 yrs old, 6' 3" or less, and 200 lbs or less.
First Name: Last Name:
Are you at least 18 years old? ---- Yes No
Height: Weight: Service, Department or Hospital Affiliation:
Certification (check all that apply):
First Responder: EMT: EMT-P: RN: MD: Fire Fighter: Police Officer: Other: 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. 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.
