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2. Instructions
   Use this form to record EMS shifts, the number of runs while on shift, Special Events and interfacility/airport transfers.
4. First Name*
5. Last Name*
6. Date*
8. Hours on Shift
9. Number of Runs
10. Describe Shift
12. Date
13. Hours on Transfer
14. Describe Transfer
16. Date
17. Hours on Special Event
18. Describe Special Event
20. Captain on Duty
22. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
24. Electronic Signature*
26. Chief Signature and Date
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field