Stars of Life Recipient Form

Award Recipient Information

Name (as you would want it to appear in conference materials) *

First

Middle

Last

Birthdate *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Your Cell Number *

Will you fly to the conference? *

teams, Address state}

If YES, will Medic book your airfare? *

Please note: Stars are welcome to book their conference airfare. Some Stars want to use upgrade/points when booking their airfare. In that case, Medic will reimburse a predetermined amount for airfare. Anything over that amount is the employee's responsibility.

Your Travel Guest

Guest Name

First

Middle

Last

Guest Birthdate

Cell Number

Are you bringing a child/children?

Child's Name

First

Last

Attire

Field & CMED Stars should bring Class A shirts in excellent condition, 1 badge and 1 uniform dress tie. Admin & Support Roles are expected to bring 2 long sleeve button down shirts branded with Medic’s logo.

I need to order 2 class A shirts
I need to order 1 class A shirt
I do not have a badge
I do not have a tie
I am Admin/Support and need to order branded shirts

Check all that apply.

Biography Questions

When and where did you begin your EMS career?

If you did not begin your EMS career at Medic, what was the progression leading you here? (i.e. started as an EMT in {insert state} before going to Paramedic school {insert name of school} etc.

What year did you start at Medic?

What roles or titles have you held at Medic?

Do you do anything EMS related outside of Medic? (i.e. instructor, special events)

Is there any EMS related accomplishment that you are most proud of?

Field or CMED employees only: is there any 911 call that you are most proud of and/or impacted you in a positive way?

List any committees or groups you are a part of. (i.e. volunteer work or professional associations)

List any standout experiences, certifications, awards or projects you have been a part of. (i.e. project teams, initiatives etc)

Award Recipient Information

Your Travel Guest

Attire

Biography Questions

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