Accountability Tag Form

All members of the Phillipsburg Emergency Squad are required to have Accountability Tags. If you do not have a set, please fill out the form below

ACCOUNTABILITY tags

Application Type *

Initial Request Update Request Replacement Request Renewal Request

Qualifications *

EMT / Paramedic - GREEN Non-EMT - BLUE Rescue Only - RED Cadet (under 18) - ORANGE

* Indicates required field

Applicant Name *

First

Last

ID # (If Known) *

Date *

Blood Type *

Email *

Blood Pressure *

Pulse *

DOB *

Gender *

Medical History *

Medications *

Allergies *

Organ Donor *

Religion *

Physician *

Emergency Contact Name 1 *

First

Last

Emergency Contact Name 2 *

First

Last

Emergency Phone 1 *

Relation 1 *

Emergency Phone 2 *

Relation 2 *

Please verify all information carefully before submitting information. By hitting "submit" you certify all information is correct and will be used in an emergency situation.

Submit

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