OSES Online Application

PERSONAL INFORMATION


First Name	MI	Last Name

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Date of Birth (MM-DD-YYYY)		Student ID Number (Not your SSN)		Grade Status

Local Address


City	State	Zip Code

(You may change automatically entered data as necessary.)

() -	() -
Local Phone	Cell Phone

Home Address


City	State	Zip Code


E-Mail Address	AIM Screen Name

Are you currently a SUNY Oneonta Student? YES NO
Are you currently a SUNY Oneonta Faculty Member? YES NO
Are you currently employed by SUNY Oneonta? YES NO
Are you currently a Hartwick College Student? YES NO

INDIVIDUAL BACKGROUND

Are you presently under a doctor's care? YES NO
Are you currently on any medication? YES NO
Have you ever been convicted of a crime? YES NO

If you answered 'Yes' to any of the above questions, please explain:

Have you ever applied for membership to this organization
or any other health care transport squad? YES NO

QUESTIONS

Why do you want to be a part of OSES?

How can you help OSES?

Are you willing to ride once a week? YES NO
Please Explain:

Are you willing to ride any weekend shifts? YES NO
Please Explain:

OTHER EMERGENCY ORGANIZATIONS

Have you ever been a member of any Emergency Services (Fire, EMS, etc.)? If so, please list:

Squad Name	Dates (MM-YYYY)*	Contact Person	Phone
	- to -		() -
	- to -		() -
	- to -		() -

*If you are still a current member, leave the "to" date boxes blank.

CERTIFICATIONS

Please list any medical certifications or titles you hold (EMT, CPR, etc.):

Card Type	Card #	Expiration (MM-DD-YYYY)
		--
		--
		--

HEPATITIS B VACCINATION

All members of OSES are required to have the Hepatitis B shot.
You will also be required to provide documentation from a doctor.
The Student Health Center should have records of your Hepatitis B shots as well.

Have you had the Hepatitis B Vaccination? YES NO
If you know the dates of your shots, please list below.
You must provide official record of your Hepatitis B Vaccination from the Health Center before you can ride as a member.
Dose 1: Dose 2: Dose 3:

If you have not received the Hepatitis B shots, you may receive them free of charge once you are approved as a member. This is a requirement by the NYSDOH.

ADDITIONAL COMMENTS / QUESTIONS / CONCERNS?

ELECTRONIC SIGNATURE
By checking this box, I am stating that I have answered all questions
contained herein completely and TRUTHFULLY to the best of my knowledge.

WARNING: Please review all information above, once you click "Submit Application" your data will be sent to OSES, except if there is a required field with no / incorrect data, or you have not checked the box above. You will not be able to change your information once it is submitted.