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Hatzala Beit Shemesh Initial Application
This form is for use to register in a class or volunteer as a registered EMT
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Neighbourhood
*
Please Select
Ramat Beit Shemesh Aleph
Ramat Beit Shemesh Bet
Ramat Beit Shemesh Gimmel
Ramat Beit Shemesh Daled
Ramat Beit Shemesh Hey (Neve Shamir)
Sheinfeld
Nofei Aviv
Givat Savion
Givat Sharet
Nofei HaShemesh
None of the Above
Home Phone
-
Area Code
Phone Number
Cell Phone
*
-
Area Code
Phone Number
Email
*
example@example.com
TZ number or passsport (if passport specify the country)
*
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Facial picture
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Do you have reliable transportation?
*
Yes
No, but will soon
Not at the moment
I am married:
*
Yes
No, but I am engaged to be married
No
I can be contacted via (select all applicable answers):
*
Home Phone
Cell Phone
WhatsApp
SMS
Email
I currently volunteer in:
Magen Dovid Adom
United Hatzala
Police
Fire Department
Hatzala in another country not certified by MDA
Hatzala in another country certified in Israel under MDA
Do you hold a current חובש or paramedic license?
Yes, חובש
Yes, Paramedic
I am an ambulance driver
I don't hold any EMS certifications
I hold an EMT or Paramedic certification in another country
Please submit a copy of your valid certificate.
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If you were referred by a current HBS volunteer, please let us know which volunteer:
First Name
Last Name
If you have any questions, please let us know, and we will get back to you soon:
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