BARS Membership Application

BARS Membership Application
Personal Information:
Full Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mobile Number*

Area CodePhone Number
Home Number*

Area CodePhone Number
E-mail*
Drivers License #
Expiration Date

MonthDayYear
Issuing State
Are You a U.S. Citizen?*

YesNo
Have you ever been convicted of a crime? YES NO (Answering yes is not an automatically disqualifying item. Please provide additional information on supplemental page.)*

YesNo
Have you ever had a traffic violation? YES NO (Answering yes is not an automatically disqualifying item. Please provide additional information on supplemental page.)*

YesNo
Have you ever been investigated by a government agency for fraud or abuse? YES NO (Answering yes is not an automatically disqualifying item. Please provide additional information of supplemental page.)*

YesNo
Birth City, State, Country*
Supplemental Info
EMS Experience
Certification Level*
Date You Can Start*

MonthDayYear
Date
NREMT Cert #
Expiration Date

MonthDayYear
Date
VT EMS License #
Expiration Date

MonthDayYear
Date
BLS CPR Cert Expiration Date

MonthDayYear
Do you hold any current Instructor Certifications?

YesNo
If so which?
Have you operated with an EMS agency in another state?

YesNo
If so which state/agency?
References:
Personal Reference *
Name of Reference
Relationship*
Years Acquainted*
Phone*
Email*
Personal Reference
Name of Reference
Relationship
Years Acquainted
Phone
Email
Professional Reference*
Name of Reference
Job/Title*
Years Acquainted*
Phone*
Email*
Professional Reference
Name of Reference
Job/Title
Years Acquainted
Phone
Email
Skills/Qualifications:
Skills
List any relevant skills
Qualifications
List any relevant certifications or qualifications
Availability
What availability do you have to offer Brandon Rescue?
Organizational requirement include 24 hours per month of duty be scheduled. Do you have any concerns about meeting this requirement for the foreseeable future?*

YesNo
Information Release Agreement
To the best of my knowledge, all the statements and information in this application is true and complete. It is understood that an incomplete or misleading application is sufficient grounds for immediate dismissal or
suspension from Brandon Area Rescue Squad.

I, Full Name* do hereby authorize a review and full disclosure of
all records, or any part thereof, concerning myself by/to any duly authorized agent of the Brandon Area Rescue Squad, whether the said record(s) are public or private, and include those which may be deemed to be of a privileged or confidential nature. The intention of this authorization is to provide information that will be utilized for
investigation resources material.
Signature*

Clear
Date*

MonthDayYear
Background Check Agreement
I authorize Brandon Area rescue Squad to complete a background check (to include motor vehicle and criminal both at the state and national levels) based upon this application.
Signature*

Clear
Date*

MonthDayYear
SSN*
Confidentiality Agreement
Brandon Area Rescue Squad (BARS) is committed to safeguarding the privacy of its patients and to maintaining the confidentiality of health information. BARS employees, volunteers and students must make every effort to prevent unauthorized disclosures of medical, personal or organizational data pertaining to patients, employees
and service operations. In the course of your membership/employment at BARS you may come into possession
of confidential information. It is imperative as a condition of your membership/employment that you adhere to policies governing the release of patient information and uphold privacy guidelines. Under no circumstances should patient information be released or discussed with anyone unless it is in the performance of job-related
duties. To ensure that you acknowledge your responsibility to protect the privacy and confidentiality of patient information, please read and sign the following:
1. I acknowledge that all information is confidential and protected against unauthorized viewing, discussion
and disclosure.
2. I understand that this information is privileged and confidential regardless of format: electronic, written,
overheard, observed or verbal.
3. I understand that I may view, use or copy information only as it relates to the performance of my
job/assignment responsibilities. Any unauthorized viewing, discussion or disclosure of this information is
prohibited.
4. I will comply with any security or privacy policies of BARS to protect the privacy and security of
confidential information.
5. I acknowledge that my signature on this Confidentiality Agreement signifies I have read, understood and
am committed to its principals and terms.
6. I understand that violation of this agreement will result in disciplinary action or the appropriate sanctions,
up to and including termination, even for the first violation.
7. I understand that this signed and dated document will become part of my permanent record.
8. I understand and agree that this is not and does not create a contract of employment.
Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
By clicking the submit button below, I cerity that all of the information provided by me on this application is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application may be rejected and, if I am employed, my employement may be terminated at any time. In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compenstation can be terminated, with or without cause, and with or without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company.
Signature*

Clear
Should be Empty:

BARS Membership Application

Personal Information:

EMS Experience

References:

Skills/Qualifications:

Availability

Information Release Agreement

Background Check Agreement

Confidentiality Agreement