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Haverstraw Ambulance Corps Online Application

Home » Join Us » Haverstraw Ambulance Corps Online Application

Step 1 of 3

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Today's Date(Required)

PERSONAL INFORMATION

Name(Required)

First Middle Last

CONTACT INFORMATION

Address(Required)

Street Address City State ZIP Code

Home Phone

Work Phone

Cell Phone(Required)

Email(Required)

CONTACT INFORMATION

Position(s) Applying For:(Required)

EMT

Driver

Helper

Non-Riding

Junior Corps (if under 18 years old)

GENERAL INFORMATION

Are you a citizen of the United States?(Required)

Yes

No

Do you have a valid New York State Driver’s License?(Required)

Yes

No

Have you ever been convicted of a crime?(Required)

Yes

No

If Yes, Please Explain Fully(Required)

Have you ever been a member of any ambulance corps, fire/rescue department, or service club?(Required)

Yes

No

If yes, where and when(Required)

Have you ever been removed from membership from any ambulance corps, fire/rescue department or service club?(Required)

Yes

No

If Yes, Please Explain Fully(Required)

AVAILABILITY

Membership in our organization requires regular attendance and participation in Corps activities (meetings, training/drills, answering emergency calls if a riding member, etc). Scheduling is flexible and training is provided at no cost. Please check the time period that would best allow you to volunteer your time to help the Corps and the community. Please check the time period that would best allow you to volunteer your time to help the Corps and the community.

Weekdays:

Days

Evenings

Nights

Weekends:

Days

Evenings

Nights

EDUCATION

High School(Required)

College(Required)

Have you ever been trained in CPR?(Required)

Yes

No

Are you CPR Certified?(Required)

Yes

No

If yes, what is the exp. date?(Required)

Are you a certified NYS EMT?(Required)

Yes

No

If yes, what is the exp. date?(Required)

If yes, where did you receive the training?(Required)

Please note any other medical training, skills and/or certifications

Have you taken a Defensive Driving Course?(Required)

Yes

No

If yes, what was the date?(Required)

Have you taken EVOC or CEVO?(Required)

Yes

No

If yes, what was the date?(Required)

EMPLOYMENT HISTORY

Are you currently employed?(Required)

Yes

No

Have you ever worked or held a job?(Required)

Yes

No

Current Employer

Company Name:(Required)

City(Required)

State(Required)

Position / Type of Work(Required)

Start Date(Required)

End Date

Immediate Supervisor:(Required)

Phone Number(Required)

Previous Employer

Company Name:(Required)

City(Required)

State(Required)

Position / Type of Work(Required)

Start Date(Required)

End Date

Immediate Supervisor:(Required)

Phone Number(Required)

Do you have additional employment history to add?

Yes

No

Previous Employer #2

Company Name:(Required)

City(Required)

State(Required)

Position / Type of Work(Required)

Start Date(Required)

End Date

Immediate Supervisor:(Required)

Phone Number(Required)

REFERENCES

Provide three (3) references not related to you that we may contact.

Reference #1 Name(Required)

First Last

Reference #1 Address(Required)

Street Address City State ZIP Code

Reference #1 Phone(Required)

Reference #1 Email(Required)

Reference #1 Years Known(Required)

Reference #2 Name(Required)

First Last

Reference #2 Address(Required)

Street Address City State ZIP Code

Reference #2 Phone(Required)

Reference #2 Email(Required)

Reference #2 Years Known(Required)

Reference #3 Name(Required)

First Last

Reference #3 Address(Required)

Street Address City State ZIP Code

Reference #3 Phone(Required)

Reference #3 Email(Required)

Reference #3 Years Known(Required)

CONDUCT LETTER

Go to your local police department and request a letter of conduct.

Acknowledgement

I confirm that I will obtain a conduct letter from my local police department as part of this application process.

As part of the application process, you are required to obtain a conduct letter from your local police department. This letter verifies your character and confirms that you have no disqualifying criminal history. Please contact your local police department to request this document, as processing times may vary. The letter must be submitted to our department as soon as possible. Failure to provide this letter may result in delays or disqualification from the application process.

AGREEMENT

I understand and agree to the following:

I agree to the privacy policy.

The information provided in the forgoing application is true and complete. I understand that any falsification, misrepresentation or willful omission of facts in this application shall be sufficient cause for refusal of membership or discharge from the Haverstraw Ambulance Corps.
2. I understand that I will be required to participate in an interview with the Membership Committee and be subject to applicable background checks as a part of this application process.
3. I acknowledge my obligation to abide by all rules, regulations and policies of the Haverstraw Ambulance Corps as defined in the Corps Constitution, By-Laws, and Standard Operating Procedures.

Name(Required)

First Last

Date

Signature(Required)

PARENTAL CONSENT FOR JUNIOR CORPS APPLICANTS- under 18 years old:

I agree to the privacy policy.

Corps policy permits Junior Corps members to respond on ambulance calls until 10:00 pm on school nights and until Midnight on all non-school nights. I am the parent or legal guardian of this applicant. I have reviewed and approve this application. I give permission for the applicant to engage in Ambulance Corps authorized activities.

Name

First Last

Date

Month

Day

Year

Parent/Guardian Signature

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EMERGENCY: 911
845-947-5550
160 North Route 9w
Haverstraw, NY 10927

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