GEMRU Responder Background – Gator Emergency Medical Response Unit

GEMRU Background

This form is to be completed during the second round of the formal application cycle. Please do not complete this form until instructed by GEMRU.

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This field is for validation purposes and should be left unchanged.

Name(Required)

First Middle Last

UFID #(Required)

Only UF Students are allowed to join GEMRU.

Date of Birth(Required)

Place of Birth(Required)

DL#/ID#(Required)

ID Type(Required)

Example a Class C License

Issuing State/Nation(Required)

LAST 4 of Social Security Number(Required)

Race(Required)

Sex(Required)

Eye Color(Required)

Hair Color(Required)

Height(Required)

Weight(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Select the providers level of care(Required)

EMR

EMT

EMT/LEAD

EMT License Number(Required)

By submitting this application, you agree to accepting a friend request by UFPD.

Facebook - If not applicable, please write N/A(Required)

Instagram - If not applicable, please write N/A(Required)

Twitter - If not applicable, please write N/A(Required)

Other - If not applicable, please write N/A(Required)

Name(Required)

First Last

Relationship(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Photograph(Required)

Accepted file types: jpg, jpeg, png, gif.

Please take a photograph of yourself on a neutral wall color and attach to your application