Medical Badge – Application Form
Medical Badge – Application Form
SGAUS membership required. Incomplete applications will not be processed.
SGAUS Medical Badge Guide: DO NOT APPLY TO THE MEDICAL ACADEMY. WE ARE UPDATING THE REQUIREMENTS. NO APPLICATIONS WILL BE PROCESSED AT THIS. NEW REQUIREMENTS WILL BE POSTED ASAP. FOR QUESTIONS YOU MAY EMAIL
MEMBER.SERVICES@SGAUS.ORG
.
Date
Name
*
Name
First Name
First Name
Last Name
Last Name
Middle Initial
Personal Email
*
IE: joe.snuffy@gmail.com
Official Email
*
IE: joe.snuffy@army.mil | joe.snuffy@zulustateguard.gov
Rank
*
Spelled out – IE: Staff Sergeant (Do not include numbers, state, US, etc)
Service
Spelled out – IE: Air Force, Air National Guard, Zulu Defense Force. If not in a service: Leave Blank
Address
*
Address
Address
Address
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Phone
*
I am a SGAUS Member
*
Yes
No
Military/Civilian Resume
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
PDF Only
Requested Badge Level
*
Basic (EMT)
Senior (Paramedic)
Master (Clinician)
Letter of recommendation (Senior/Master Badge)
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Letter of recommendation from a supervisor/unit commander/colleague that attests to your Emergency Medical and/or Leadership skills.
Certificate Upload – IS-100
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – IS-200
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – IS-300
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – IS-700
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – IS-800
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – Emergency Medical Technician (EMT)
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor.
Certificate Upload – NIMS Medical Unit Leader Position Task Book (PTB)
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Download blank form here: https://www.fema.gov/sites/default/files/documents/fema_medical-unit-leader-ptb.pdf Note: This document must be initiated and certified by your local State Defense Force command (not SGAUS) before you upload the completed scan.
Certificate Upload – Certificate of Completion from a HazMat Awareness course (e.g., FEMA, TEEX, CDP, or an organizational training program)
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – Ambulance and Emergency Vehicle Operations –Certificate of Training from a recognized course (e.g., CEVO, EVOC, or state-level emergency vehicle operator course).
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor.
Certificate Upload – Respiratory Protection 1. Certificate of Training (must be current) AND 2. Respirator Fit Test Documentation (a signed form or card showing you passed a qualitative or quantitative fit test within the last 12 months for the specific respirator you use) AND 3. Medical Clearance Documentation (proof of medical evaluation/clearance to wear a respirator).
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – Bloodborne Pathogens – Certificate of Training
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – IS-368: Access and Functional Needs in Disaster Operations
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – Psychological First Aid course (Red Cross or equivalent)
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – Active legal authority (state / territorial license) as an MD/DO, NP, or PA
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – Current DEA Registration
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – Active legal authority to function as a Paramedic (State / Territorial License or Registration)
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – Completion of a Paramedic Training Program
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Certificate Upload – Graduate of an accredited MD, DO, NP, or PA program
*
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Official Certification Certificate as issued from certification vendor
Blue Flash
*
Yes, requesting
No, not requesting
Blue Flash – Documentation (Orders or Awards) demonstrating past activation specifically within this specialty
Drop a file here or click to upload
Choose File
Maximum file size: 5MB
Submit
If you are human, leave this field blank.