Base Hospital Affiliation Form 

This form is required to be filled out before working as an EMCT under Mt. Graham Regional Medical Center EMS Base Hospital. By submitting this form, you agree to the release of this information for official Base Hospital use only. If at anytime you would like this information changed or redacted, please contact the Prehospital Coordinator by using the contact information at the bottom of the page.

Name *
Name
Phone *
Phone
Add to EMS Emergency Notification System? *
By selecting yes, your phone # will be added to a group database for notifications in the event of mass casualties, disasters, etc. Your phone # will remain private & nobody sending or receiving the group message will be able to see your phone #. You can redact this information at anytime by contacting the Prehospital Coordinator.
Primary Agency Affiliation *
Choose the primary agency where you practice EMS. If your primary agency is not under this Base Hospital, choose “Other Agency” and list it below.
Secondary Agency Affiliations
Choose all secondary agencies where you practice EMS. If your secondary agencies are not under this Base Hospital, choose “Other Agency” and list it below. Skip this question if you have no secondary agencies.
If directed above, list the agencies you are affiliated with that are not based under Mt. Graham.
Ignore the letter at the beginning of your certification #
AZ DHS Expiration Date *
AZ DHS Expiration Date
Ignore the letter at the beginning of your certification #. Skip this if you do not have a current National Registry Certification
NREMT Expiration Date
NREMT Expiration Date
Skip this if you do not have a current National Registry Certification
BLS Provider is required for all EMCTs. ACLS/PALS are required if you are an ALS Provider.
BLS Provider Expiration (CPR Card) *
BLS Provider Expiration (CPR Card)
ACLS Expiration
ACLS Expiration
PALS Expiration
PALS Expiration
Previous Base Hospital Information
This is only required if you are transferring here from another Base Hospital. Leave this blank if this is your first EMS job or you are transferring between agencies based under Mt. Graham.
Previous Prehospital Coordinator
Previous Prehospital Coordinator
or Base Hospital Manager, etc.
Attestation
By typing your name below, you agree to follow all Base Hospital Policies & Procedures including knowing and understanding all current and future Policies, Orders, and Protocols set forth by Mt. Graham Base Hospital.