Volunteer Heart Ambulance

PO Box 060252

Staten Island, New York 10306

718-979-5850

http://www.vollyheart.com

Membership Application

Please be sure to fill in all boxes and answer all questions.

Anything with an asterisk (*) in front of the box means the box must be filled in.

Today's Date (00/00/00) *

Name * D.O.B. (00/00/00) *

Address * 

City * State * Zip Code *

Home Telephone # ( * ) * - *                Work Telephone # ( ) -

Pager # ( ) -                                   Cell Phone # ( ) -

E-mail Address

Emergency Contact Information

1.Who to contact: *

Relationship to you: *

Their Phone Number (*) *

2. Who to contact:

Relationship to you:

Their Phone Number ()

3. Who to contact:

Relationship to you:

Their Phone Number ()

Please indicate position you are applying for? You must be a NYS certified EMT.

* EMT Administrative

 EMT # Expiration Date

Driver’s License State   Driver’s License # Drivers License Expiration

Present Employer

Position

 Address

City State Zip Phone #

Previous Employer

Position

 Address

City State Zip

Highest Level of Education 

* High School Graduate Some College College Graduate   Degree? 

Have you ever been convicted of a felony? * Yes No

If yes please explain

Do you have previous experience driving an Emergency Vehicle * No Yes   

If yes please indicate where and for how long:

Have you been or are you a member of another Volunteer Ambulance Corps? * No Yes

 Name of Corps.  

Joined   Still Active Yes No    

 References:

Name * Telephone # ( * ) * - *

Relationship* How Long *

Name * Telephone # ( * ) * - *

Relationship* How Long *

Name Telephone # ( ) -

Relationship How Long

Do you have any particular skills, which may benefit V H A? (Besides the position you are applying for)

  Yes No         If yes please explain:

 I, *, hereby state that the information contained in this application is true to the best of my knowledge, and that any false statements made by me may result in immediate dismissal from Volunteer Heart Ambulance. If accepted as a member, I agree to adhere to the Units Current By-laws and Standard Operating Procedures. I understand that once accepted as a member I will be on probation for a period of six months, during this time the current officers and committee heads will evaluate me regarding my performance. I also understand that the units Medial Director may request a medical report from my private physician indicating that I am fit to perform the duties and responsibilities of a Emergency Medical Technician, Fist Aider or Motor Vehicle Driver at any time during my membership.

_____________________________________________________________ Date * / * / *

                        Signature of Applicant    

By checking this box, you are electronically signing the above truth statement.