SPAC: Association Application (Version 1.0)

Stony Point Ambulance Corps

Association Application
Dear Applicant,

We are thrilled to receive your application for membership with the Stony Point Ambulance Corps, Inc. Thank you for expressing your interest in joining our team of dedicated volunteers who provide life-saving services to our community.

We understand that completing an application can be a time-consuming process, but please know that your efforts are greatly appreciated. Your commitment to providing accurate and detailed information is essential to ensuring that we can evaluate your application thoroughly and fairly.

Upon completion of your application, please forward all documents listed below, as applicable, to membership@spacems.org. Upon receipt and review of your application, the membership committee will contact you to discuss the next steps in our membership process.

Document Checklist:
- Drivers License
- EMT Card
- CPR Card
- Blood-Borne Pathogens
- Workplace & Sexual Harassment
- HIPPA Compliance
- FEMA IS-005
- FEMA IS-100
- FEMA IS-200
- FEMA IS-700
- FEMA IS-800
- 2019 BLS Protocol Update (if applicable)
- HVREMCO S-Lams Protocol Update (if applicable)
- Records check letter from the Stony Point Police Department
- Records check letter from your local police department (if not Stony Point)
Once again, thank you for your interest in becoming a member of the Stony Point Ambulance Corps, Inc. We are excited to learn more about you and to have the opportunity to work together to serve our community.

Please feel free to contact us at membership@spacems.org with any questions or concerns.

Contact Information:
Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.
Address:*

Street Address

Street Address Line 2

CityState

Zip Code

EMS Experience

Provide at least one place of EMS involvement if applicable. Begin with your current or most recent EMS involvement.
Experience Acknowledgment:*

I acknowledge that I have been involved in at least one EMS agency.I acknowledge that I have NOT been involved in any EMS agency.

Agency (1)
Agency Name:*
Phone Number:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Role:*
Type:*

VolunteerEmployee
Duties & Responsibilities: *
Supervisor's Name:*

First NameLast Name
Supervisor's Phone Number:*
Please enter a valid phone number.

Agency (2)
Agency Name:
Phone Number:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState

Zip Code
Role:
Type:

VolunteerEmployee
Duties & Responsibilities:
Supervisor's Name:

First NameLast Name
Supervisor's Phone Number:
Please enter a valid phone number.

References

To the best of your ability, please list three (3) references that you are NOT related to.

	Reference #1	Reference #2	Reference #3
Name
Address (City, State)
Phone Number
Email
Occupation

Federal Driver's Protection Act:

Authorization to Obtain Motor Vehicle Report
For the sole purpose of the determination and evaluation of my motor vehicle authorize the Stony Point Ambulance Corps, Inc. and its insurance carrier to obtain my Motor Vehicle Record. I understand that this record may contain personal information* in addition to any/and driver violations and/or accidents, which may be on record through the NYS Department of Motor Vehicles.

I also authorize the release of the following information to my employer:
- Driver's License Number
- Driver's License State
- Date of Birth
- Street Address
*Personal information means information that identifies an individual including an individual’s photograph, social security number, driver’s license identification number, name, address, and telephone number. It does not include information on vehicle accidents, driving violations, and driver status.
Signature of Applicant*

Clear

Records Inquiry:

Authorization to make Records Inquiries
I authorize the Stony Point Ambulance Corps, Inc., to make inquiries into all my records, including but not limited to criminal history, driving records, as well as employment, education, and training history. I further authorize and give permission to the Corps to contact the references I designated in my application for employment with the Stony Point Ambulance Corps, Inc. I understand that all information will be kept confidential and used for the purpose of my eligibility for employment with the Corps and services of the Corps to the community.
Signature of Applicant*

Clear

Association Application Acknowledgment :
I fully understand and certify the following:
1. The information provided in this application is complete and accurate to the best of my knowledge. I understand that any falsification, misrepresentation, or willful omission of facts called for in this application may jeopardize my eligibility for membership now or in the future.
2. I will be required to participate in an interview with the Membership Committee and be subject to applicable background checks as part of the application process.
3. I give Stony Point Ambulance Corps, Inc. and/or Officers of the Corps permission to thoroughly investigate and verify all information provided in this application, or related associated documentation, and during interviews. I authorize all references named herein unless otherwise noted, to provide any information requested about me, and I release them from liability for damage in providing this information.
4. I understand that Stony Point Ambulance Corps, Inc. requires a minimum availability of 12 hours per month.
5. I will be required to be complete training as either an EMT, EVO (Driver), or both.
6. I understand that, if accepted into Stony Point Ambulance Corps, I will be required to follow all Bylaws and Standard Operating Procedures.
Signature of Applicant*

Clear
Please verify that you are human*
Should be Empty:

	Yes	No
Have you ever been convicted of a felony?
Have you ever served in the Armed Services?
Have you ever received a discharge from the Armed Services, that was less than honorable?
Have you ever been involuntarily removed from employment, membership, in any public service fraternal organization or service club?
Is there any reason why you could not safely perform ALL required duties without exposing yourself or others to harm?
Do you have ANY medical conditions that would prevent you from safely performing ALL required duties, including operating an emergency vehicle?
Have you ever been placed on probation or terminated from excessive absenteeism?
Have you ever been disciplined or fired for excessive lateness?
Have you ever been disciplined or fired for insubordination?
Have you ever been disciplined or fired for violation of safety rules?
Have you ever been disciplined or fired for assault or fighting?
Have you ever been disciplined or fired for patient abuse?
Have you ever been disciplined or fired for alcohol or drug related activity while at work?
Do you have any psychological and/or substance abuse conditions which may limit your ability to perform any aspect or any function in this position?

	Yes	No
Are you in an overall state of health that may prevent you from preforming the essential duties of this job?
Have you had any previous injuries that may prevent you from preforming the essential duties of this job?
Do you have any physical or mental impairments?
Do you have or have ever had: Heart problems?
Do you have or have ever had: Vertigo?
Do you have or have ever had: Joint/Neck/Back Problems?
Do you have or have ever had: Hernia?
Do you have or have ever had: Epilepsy?
Do you have or have ever had: Asthma?
Do you have or have ever had: COPD/Emphysema?

	Current	Expired	N/A
NYS EMT
AHA CPR
Blood Borne Pathogens
Driver's License
CEVO/EVOC/EMSVO
NYS 2019 BLS Update (If Applicable)
HVREMCO S-LAMS Update (If Applicable)
FEMA IS-100 (Does not Expire)
FEMA IS-200 (Does not Expire)
FEMA IS-700 (Does not Expire)
FEMA IS-800 (Does not Expire)
FEMA IS-005 (Does not Expire)

Stony Point Ambulance Corps

Contact Information:

EMS Experience

Certifications

References

Federal Driver's Protection Act:

Records Inquiry:

Association Application Acknowledgment :