Membership Application

Levittown-Fairless Hills Application Form

LFHRS is an equal opportunity employer. We consider applications for all positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, disability, genetic information or any other factor protected by law. This application will be kept on file for a period of not greater than six months from the date submitted.
What type of membership are you applying for at this time?*
Volunteer Application

Thank you for choosing to complete an application for Levittown Fairless Hills Rescue Squad (LFHRS). Once your application is submitted, LFHRS staff will review your information, and contact your references. Once references are completed and upon determining your eligibility, you will be contacted by phone
and/or email address to schedule an interview. The following criteria must be met before completing the application:
- Must be at leaset 16 years of age
- Successfully complete First Aid course (or equilvalent) or have a valid EMT, AEMT, Paramedic, PHRN, or Prehospital EMS Physician certification.
- Must have valid working papers if under 18 years old or authorized to work in the United States
- Must have a valid Basic Life Support CPR certification (BLS CPR)
Please note: All sections of the application need to be completed. Any missing information can cause a delay in the processing of your application. Feel free to call 215-547-2822 x 130 or email lfhrs@lfhrs.com with questions about the application and hiring process.
Career Application

Thank you for choosing to complete an employment application for Levittown Fairless Hills Rescue Squad (LFHRS). Once your application is submitted, LFHRS staff will review your information, and contact your references. Once references are completed and upon determining your eligibility, you will be contacted by phone and/or email address to schedule an interview. The following criteria must be met before completing the application:

• Must be at least 18 years of age
• Must have a valid EMT, AEMT, Paramedic, PHRN, or Prehospital EMS Physician certification
• Must be authorized to work in the United States
• Must have a valid driver’s license

Please note: All sections of the application need to be completed. Any missing information can cause a delay in the processing of your application. Feel free to call 215-547-2822 x 130 or email lfhrs@lfhrs.com with questions about the application and hiring process.

Section 1 - Personal Information
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you at least 16 years old?

YesNo
Are you at least 18 years old?

YesNo
Date of Birth

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Verify your current age
Do you have a valid Driver's License?
Driver's License State
Driver's License Number
Driver's License Expiration Date

MonthDayYear
Date
Upload a copy of your driver's license

Cancelof
Email Address*
example@example.com
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.

Section 2 - References

(Please list at least three references – Do not include current or former LFHRS members or relatives)
Reference 1 Name
Reference 1 Phone Number
Please enter a valid phone number.
Reference 2 Name
Reference 2 Phone Number
Please enter a valid phone number.
Reference 3 Name
Reference 3 Phone Number
Please enter a valid phone number.

Section 3 - EMS Training

Please indicate your status on all of the following certifications.
Highest Current Certification Level
Certification Number
Certification Expiration Date

MonthDayYear
Date
Upload a copy of your highest current certification

Please upload a copy of your certification, both front and back (where applicable).
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Endorsements (optional)

EMSVOInstructor
EMSVO Expiration Date

MonthDayYear
Date
Instructor Expiration Date

MonthDayYear
Date
EVOC Certification
EVOC Issued Date

MonthDayYear
Date
EVOC Documents

Please upload EM SVO certification documents
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IS Certifications (check all that apply)

100200300400700800
IS-100 Issued Date

MonthDayYear
Enter the date you IS-100 certification was issued
IS-200 Issued Date

MonthDayYear
Enter the date you IS-200 certification was issued
IS-300 Issued Date

MonthDayYear
Enter the date you IS-300 certification was issued
IS-400 Issued Date

MonthDayYear
Enter the date you IS-400 certification was issued
IS-700 Issued Date

MonthDayYear
Enter the date you IS-700 certification was issued
IS-800 Issued Date

MonthDayYear
Enter the date you IS-800 certification was issued
IS Certification Documents

Please upload all IS Certification documents
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HAZMAT Certification
HAZMAT Issued Date

MonthDayYear
Date
HAZMAT Documents

Please upload HAZMAT certification documents
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BLS CPR Certification
BLS CPR Expiration Date

MonthDayYear
Date
BLS CPR Documents

Please upload BLS CPR certification documents
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ACLS Certification
ACLS Expiration Date

MonthDayYear
Date
ACLS Documents

Please upload ACLS certification documents for validation
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PALS Certification
PALS Expiration Date

MonthDayYear
Date
PALS Documents

Please upload PALS certification documents
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PHTLS Certification
PHTLS Expiration Date

MonthDayYear
Date
PHTLS Documents

Please upload PHTLS certification documents
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TECC Certification
TECC Expiration Date

MonthDayYear
Date
TECC Documents

Please upload TECC certification documents
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TCCC Certification
TCCC Expiration Date

MonthDayYear
Date
TCCC Documents

Please upload TCCC certification documents
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Section 4 - Employment History
Not applicable to Volunteer applicants. Please click next to proceed to the next section.
Employer 1
Employer 2
Employer 3

Section 5 - Previous Membership Information
Have you ever been a member of LFHRS before?
Previous Position Held at LFHRS
From and until when were you previously a member of LFHRS
Reason for leaving LFHRS

Section 6 - Education
Did you attend college/university?
Did you attend vocational or other training?
College
Vocational / Other Training
High School

Section 7 - General Information
Referred By:
Do you have any friends or relatives that are currently members of LFHRS?
Please indicate who and your relationship to them
Please explain why you want to become a member of LFHRS

Section 8 - Emergency Services Experience
Are you currently an emergency driver at any other emergency service(s)?
Please indicate where you are currently an emergency service(s) driver
Do you have Bucks County Command status?
When did you obtain Bucks County command status?
Do you have Command Status in any other region?
Please indicate where else you have command status, and when it was obtained
Are you a member of any other emergency service? (ambulance, fire, police, etc)
Please list other EMS affiliates and their telephones numbers

Section 9 - Background Clearances
Has your driver's license ever been suspended or revoked?
Please explain in detail why it was suspended or revoked
Have you ever been convicted of any crime (including misdemeanor or felony) and/or for any motor vehicle violations in Pennsylvania or any other state?
Please explain in detail
LFHRS will conduct reference, educational, and other checks on all applicants. In addition, all applicants must provide LFHRS with four (4) specific background clearances once an offer has been made. LFHRS requires the following background clearances:

1. Criminal Record Check;

2. Child Abuse History Clearance;

3. The Federal Bureau of Investigation Criminal Background Check; and

4. Driver's license background check for state where your license is issued.

I understand that any falsification of any information automatically voids my application. I hereby give Levittown-Fairless Hills Rescue Squad and their employees, representatives or agents, and the local police department(s) permission to investigate my criminal and other background and obtain any information deemed to be necessary for the completion of this application.
Section 9: Signature of Applicant*

Clear
Date

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date

Section 10 - Application Certification & Acknowledgement
I hereby certify that the information set forth in this application are true and complete and agree to the following:

I have not knowingly withheld any information that might, if disclosed, affect my application unfavorably. I understand that if any statement made by me on this application or during the pre-approval process is false, misleading, or a material omission, it will prevent me from becoming a member, or it will be grounds for my immediate dismissal, regardless of when discovered by LFHRS.

I also understand that any offer of employment or volunteer position for any individual over the age of 18 is conditional upon satisfactory background clearances. I further understand that any offer of employment or approval for any other position is conditional upon a negative drug and alcohol test. If the background clearances or drug and alcohol testing is not satisfactory to LFHRS, the offer of employment or approval of other status will be withdrawn or, if I have been subsequently employed or approved, employment or other status may be terminated.

I expressly authorize, without reservation, LFHRS, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have against LFHRS, its agents, employees or representatives, for seeking, gathering and using this information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

In consideration of my membership or position, I agree to conform to LFHRS’s policies and regulations, and I understand that these policies/regulations, forms/documents and/or the employee handbook do not form a contract of employment or any other contract, either express or implied. I also understand that any employment with LFHRS is at-will and the employment status can be terminated or changed, with or without cause and with or without notice, at any time. I also understand that any other position may be terminated or changed at any time, with or without cause
or notice.

Employment:
You must be at least 18 years of age and certified as an EMT, AEMT, Paramedic, PHRN, or Prehospital EMS Physician in order to become employed with the Levittown-Fairless Hills Rescue Squad, Inc.

I expressly agree to the Application Certification and Acknowledgment above.
Section 10: Signature of Applicant*

Clear
Date

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date

Section 11 - Drug & Alcohol Testing Consent Form
EXHIBIT A

Levittown-Fairless Hills Rescue Squad's Drug and Alcohol Policy (“the Policy”) requires that all applicants, as a condition of employment or other status, be tested for the presence of alcohol or illegal drugs. Levittown-Fairless Hills Rescue Squad will not hire or approve any applicant whose test indicates use of illegal drugs or the presence of alcohol. If you wish to be considered for employment or other status, CAREFULLY read the Drug and Alcohol Policy (link below) and sign the following consent form and release.

Click here to view the LFHRS Drug and Alcohol Policy
(this link opens in a new browser tab/window)

I HAVE READ AND UNDERSTOOD THE LEVITTOWN-FAIRLESS HILLS RESCUE SQUAD DRUG AND ALCOHOL POLICY AND THIS TESTING CONSENT FORM. I ACCEPT LEVITTOWNFAIRLESS HILLS RESCUE SQUAD’S CONDITIONS FOR CONSIDERATION FOR EMPLOYMENT OR OTHER STATUS, AND I AGREE TO BE TESTED FOR THE PRESENCE OF ALCOHOL OR ILLEGAL DRUGS. I AUTHORIZE THE TESTING AGENCY TO PROVIDE THE TEST RESULT TO LEVITTOWN-FAIRLESS HILLS RESCUE SQUAD. I ACKNOWLEDGE THAT LEVITTOWN-FAIRLESS HILLS RESCUE SQUAD IS NOT REQUIRED TO PROVIDE THE TEST RESULT TO ME UNLESS I SO REQUEST WITHIN 30 DAYS AFTER I AM NOTIFIED OF THE DISPOSITION OF MY APPLICATION. I ALSO ACKNOWLEDGE THAT I HAVE READ AND UNDERSTOOD LEVITTOWN-FAIRLESS HILLS RESCUE SQUAD'S DRUG AND ALCOHOL POLICY PRIOR TO SIGNING THIS CONSENT FORM.

I HEREBY RELEASE AND FOREVER DISCHARGE LEVITTOWN-FAIRLESS HILLS RESCUE SQUAD AND ITS AFFILIATES, BOARD MEMBERS, EMPLOYEES, REPRESENTATIVES AND/OR AGENTS FROM ANY CLAIM, LIABILITY OR OBLIGATION RELATED TO THE APPLICATION OF THIS POLICY, TESTING FOR ALCOHOL OR ILLEGAL DRUGS, USE OF INFORMATION FROM THE TESTS OR RELEASE OF SUCH INFORMATION.
Section 11: Signature of Applicant*

Clear
Date

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Levittown-Fairless Hills Application Form

Section 1 - Personal Information

Section 2 - References

Section 3 - EMS Training

Section 4 - Employment History

Section 5 - Previous Membership Information

Section 6 - Education

Section 7 - General Information

Section 8 - Emergency Services Experience

Section 9 - Background Clearances

Section 10 - Application Certification & Acknowledgement

Section 11 - Drug & Alcohol Testing Consent Form