Membership application

Dear Applicant,

Thank you for your interest in our Emergency Squad. Our squad is made up of volunteers in and around our community. We have a Senior Squad, Aux., and Junior Squad. The senior squad and Auxiliary consist of members age 18 and up. Our Junior Squad consists of students age 14 – 18. We also have a ride-along, which we offer to our junior squad age 16 and up with parents permission. We also offer a ride-along to people who are unsure if they are able to do what our organization does. This type of ride-along is valid only for 30 days.

· Please fill out the application attached to this cover letter.

o All questions must be answered to the best of your knowledge.

o Any questions not pertaining to you please write N/A

· Please submit the completed application to a member, fax it, drop it off in our mail box, or mail it to:

§ Corinth Emergency Squad, Inc.

§ 101 Sherman Ave.

§ Corinth, NY 12822

§ Fax: (518) 654-2262

· Your application will be brought to the attention of our body during our scheduled meeting. These meetings occur every other Wed. at 7:00 pm. You will be contacted as soon as possible to appear for an interview by a few of our members or to come to our meeting. So please be sure to give us an accurate phone number.

· The application process could take anywhere from 2 weeks to 2 months, depending on when we receive your completed application. To speed up the process for the senior squad (18+) you should also include a copy of:

* Your driver’s license

* Your drivers abstract (acquired at any local DMV)

* Any EVOC, or defensive driving

* Any and all prior EMS training, certifications

* Immunization record, Hep. B, PPD

Corinth Emergency Squad, Inc.

101 Sherman Ave, Corinth, NY 12822

Type of Membership

( ) Senior Squad

( ) Auxiliary

( ) Junior Squad

APPLICATION MUST BE COMPLETE

Personal Information

Last Name			First Name		Middle Initial		Gender ( ) Male ( ) Female
Current Mailing Address							DOB (MM_DD_YR)
City, State, Zip							Social Security Number
Current Home Address							Home Phone Number
City, State, Zip							Cell Phone Number
How long at this address?	U.S. Citizen? ( ) Yes ( ) No	Married ( ) Yes ( ) No		Spouse’s (or Partner’s) Name		# of dependents		Driver’s License Number

Employment Information

Current Employer			Work Phone Number
Address			How Long at this job?
City, State, Zip			Position Held
Days Worked	Hours Worked	If not working, reason unemployed?		Retired? ( ) Yes ( ) No
Additional Comments

Education and Background Information

High School

State

Course/Degree

Did you graduate?

( ) Yes ( ) No

If Yes, what Year?

College

State

Course/Degree

Did you graduate?

( ) Yes ( ) No

If Yes, what Year?

Tech/Other

State

Course/Degree

Did you graduate?

( ) Yes ( ) No

If Yes, what Year?

Have you ever been convicted of a felony? ( ) Yes ( ) No	If Yes, explain
Have you ever been convicted of a misdemeanor? ( ) Yes ( ) No	If Yes, explain
Do you have a clean driving record? ( ) Yes ( ) No	If No, list points/convictions & dates
Do you belong to any other organization? ( ) Yes ( ) No	If Yes, list
Additional Comments

Military Service

Served in the Military?( ) Yes ( ) No	If Yes, which Branch?	Length of Service	Type of Discharge
Currently in the Reserves?( ) Yes ( ) No	If Yes, provide information
Additional Comments

Previous Experience and Training

Have you ever been or are you now a EMT/ other medical?			( ) Yes	( ) No	If No, skip to the next section
If Yes, complete the following:
Emergency Squad Name	City, State	Highest Position Held		Service Dates		Reason for leaving


List Schools, training, certificates, valid cards held, etc. (Relevant to EMS duties; provide dates & expiration) and copies.

Medical History

*Please Note: This information will be kept in your personnel file. Please list any information that may be pertinent to your safety, the patient’s safety, and fellow member’s safety. This information is not used to determine your membership in our organization.

Immunizations:

Hep. B series: Date

PPD test: Date

( ) Positive ( ) Negative

Pertinent Medical History:

Any disabling injuries/dates:

List any other pertinent medical information which may affect your performance of duties as a member of this organization:

Check the applicable box(es):

( ) Motion sickness

( ) fear of blood

( ) Claustrophobia

( ) fear of vomit

Please provide two character references (non-squad members)

Name	Address	Phone
Name	Address	Phone

Why do you want to join our organization?

*Please look over your answers carefully and read the statements below before signing*

· I, _________________, certify that the information I have provided in this application is true and complete to the best of my knowledge.

· I understand that, should any information I have provided later prove to be misleading, false, or erroneous, it may result in the rejection of my application or in my subsequent dismissal from the Corinth Emergency Squad, Inc.

· I understand that I will serve a 3 month probationary period and upon completion, may be placed on a longer probationary period, accepted or rejected by a vote of the squad body, as a full active member. The decision and vote will be based on my performance and fulfillment of the requirements set forth during my probationary period.

· I understand that there is a yearly membership due of $12.00, which is part of my becoming and maintaining membership in the Corinth Emergency Squad, Inc.

· I agree to abide by the rules, regulations, and By-Laws of the Corinth Emergency Squad, Inc. both as a probationary member and as a full active member.

· I further agree that upon resignation or termination of my membership, I will return all items and equipment issued to me and owned by the Corinth Emergency Squad, Inc., including but not limited to: pager/radio, uniforms, protective gear, and any other items entrusted to me.

· By signing below, I authorize the Corinth Emergency Squad, Inc. to investigate my personal background based on the information I have provided.

· I understand that, as a Junior Squad Member, failure to maintain a passing GPA in school may result in my subsequent suspension and or dismissal from the Corinth Emergency Squad, Inc.

Signature of Applicant

Date

Signature of Parent or Guardian (for Junior Squad Member)

Date

Organization Sponsor’s Signature

Date