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2. Applications will be Processed Upon Receipt. Completed Applications will be Placed in the Department’s “Available” Intern File. Selection for Placement will be Based Upon Preceptor and Space Availability. The Napa Fire Department Paramedic Internship Coordinator will Contact You to Schedule an Interview and/or Ride Along. Thank you for Your Cooperation.
4. Applicant Information
6. First Name*
7. Middle Initial
8. Last Name*
9. Date*
   Date
11. Address*
12. Apartment/Unit #
14. City*
15. State*
16. Zip Code*
18. Phone #*
19. Email Address*
21. Date Available to Begin at NFD*
    Date Available to Begin at NFD
22. Attach photo ID*
24. Emergency Contact Information
26. Emergency Contact Name*
27. Emergency Contact Phone #*
29. Paramedic Program Information
31. Paramedic Program Name*
33. Paramedic Program Address*
35. Name of Program Director*
36. Program Directors Phone #*
38. Program Directors Email Address*
40. Name of Clinical Coordinator*
41. Clinical Coordinators Phone #*
43. Clinical Coordinators Email Address*
45. Program Emergency Contact Information

    The Person to Contact at the School in the Event of an Injury or Other Emergency

47. Emergency Contact - Name*
48. Emergency Contact Phone #*
50. Prior Internship Experience
52. Internship Agency*
53. Name of Preceptor*
55. Preceptor's Phone #*
56. Preceptor's E-mail Address*
58. From*
59. To*
60. # of Hours Completed*
62. Reason for Leaving*
64. Additional Information
66. Please Describe Your Previous EMT Experience (Cite References Such as: Agency Name, Contact Person, and Phone Number)*
68. How Will an Internship With the Napa Fire Department Benefit You?*
70. List Any Strengths and Weaknesses Identified in Your Didactic Program or Clinical Preceptorship and/or Previous Field Internship*
72. Final Agreements, Disclaimer, and Signature
74. I will be Thoroughly Knowledgeable of the Napa County EMS Protocols Prior to the Commencement of my Internship. I will Adhere to the Uniform Requirements Set by the Napa Fire Department; Dark BDU Style EMS Pants, School Uniform Shirt, Dark Work Boots With Steel Toe and an ID Badge. I will Come to my Internship Each Day With a Clean Uniform and be Well Groomed. I Certify That my Answers Throughout This Application are True and Complete to the Best of my Knowledge. If This Application Leads to an Internship, I Understand That False or Misleading Information in my Application or Interview May Result in my Release.
76. Signature*
77. Date*
    Date
Leave This Blank:


78. 1. Receive an email copy of this form.
79. Email address

    This field is not part of the form submission.

80. Submit

* indicates a required field