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Thank you for your interest in volunteering for the next Working Together Emergency Services Midwest Conference & Exposition. Please fill in all requested information below. Incomplete applications will be rejected.

Contact Information
First Name, Middle Initial
Last Name
Street Address
City, State, Zip
Phone 1
(include area code)
Phone 2 (optional)
Email Address
Are you a current WEMSA member?   Check Membership Status
If applicable, please name the referring staff member
Shirt Size
Emergency services work experience
Current Employer

Start Date

mm / dd / yy

   
Previous Employer

Start Date

mm / dd / yy

End Date

mm / dd / yy

References
Name 1

Years Known

Relation

(i.e. supervisor)
Job Title

(i.e. Director of EMS)
Service Name

City and State

Phone
(include area code)

   
Name 2

Years Known

Relation

(i.e. supervisor)
Job Title

(i.e. Director of EMS)
Service Name

City and State

Phone
(include area code)

Division applying for (check all areas of interest)
Conference Administration

Operations

 Human Resources

Registration

Exposition

Audio/Visual

Room Monitor

Speaker Introducer

Conference Runner

Airway Practical

Other
(please specify)
Available dates (check all that apply)
Monday, January 25 Friday, January 29

Tuesday, January 26

Saturday, January 30
Wednesday, January 27

Sunday, February 31

Thursday, January 28

Time Restraints
Training Background (check all that apply)
First Responder EMT-Paramedic

EMT-Basic

Registered Nurse
EMT-Intermediate Technician

Firefighter

EMT-Intermediate

Other
In case of emergency, notify...
Name
Phone
(include area code)
Relation (i.e. brother)
Street Address
City, State, Zip
Felony Conviction
Have you ever been convicted of a felony?
If yes, please explain
Signature and Date
Signature
(please type your name)
Date mm / dd / yy