SOAC: Adult Corps Application

South Orangetown Ambulance Corps

Adult Corps Application - Volunteer
Personal Information:
Name*

First NameLast Name
Date of Birth*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employment:
Are you currently employed?*

YesNo

Please provide information from up to three (3) current/former employers that we may contact. Please note in most recent order:

	Employer 1	Employer 2	Employer 3
Company Name:
City:
State:
Position:
Years Worked:
Supervisor:
Phone:

References:

Please provide the name of three (3) references not related to you that we may contact:*

	Reference 1	Reference 2	Reference 3
Name:
Phone:
Email:
City:
State:
Occupation:
Years Known:

Availability & Training:

Membership in our organization requires regular attendance and participation at Corps activities, meetings, training/drills, answering emergency calls if a riding member, etc. Scheduling is flexible and training is provided at no cost. Please check the time period that you think would best allow you to volunteer some of your time to help the Corps and the community.
I would like to primarily train as a:

Emergency Medical TechnicianEmergency Vehicle OperatorBoth

Availability :*

	Days	Evenings	Nights
Weekdays:
Weekends:

Membership Agreement:
Date:*

MonthDayYear
Date
Name*

First NameLast Name
I understand and certify the following:
1. The information provided in the foregoing application is true and complete. I understand that any falsification, misrepresentation or willful omission of facts called for in this application shall be sufficient cause for redusal of membership or discharge from the Corps.
2. I understand that I will be required to participate in an interview with Corps Officers and/or the Membership Committee and be subject to applicable background checks as a part of the application process.
3. I understand that I will need to have a physical health screening by the Corps Physician / Medical Group by the direction of the Corps and at an expense to be paid for by the Corps.
4. I give the Membership Committee and/or Officers of the Corps permissions to thoroughly investigate and verify all information provided in this application, on related associated documentation, and during interviews. I authorize all individuals, schools, and firms/employers named herein unless otherwise noted, to provide any information requested about me, and I release them from liability for damage in providing this information.
5. I understand that the South Orangetown Ambulance Corps has a monthly minimum hourly riding policy for weekend shift coverage totaling 12 hours for designated Corps approved Drivers and Emergency Medical Technicians.
6. I acknowledge the obligation on my part to abide by all the rules, regulations, and policies of the South Orangetown Ambulance Corps as defined in the Corps Constitution, By-Laws, and Standard Operating Procedures as well as the authority of the Officers of the Corps.
I promise to faithfully serve the ambulance corps and promote its interests at all times in a professional manner and to the best of my ability.
Signature:*

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Federal Driver's Protection Act

Authorization to Obtain Motor Vehicle Report
Date:*

MonthDayYear
Date
Driver's Identification Number:*
Name*

First NameLast Name
For the sole purpose of the determination and evaluation of my motor vehicle operating record and pursuant oto the State and Federal regulations of compliance, I authorize CLG Financial Corp and South Orangetown Ambulance Corps to obtain my Motor Vehicle Record. I understand that this record may contain personal information* in addition to any/all driver violations and/or accidents, which may be on record on through the states of NY, NJ, CT & all 50 U.S. States — State Department of Motor Vehicles.

I also authorize release of this information to my employer.

*Personal information means information that identifies an individual including an individual's photograph, social security number, driver identification number, name, address, and telephone number. It does not include information on vehicle accidents, driving violations, and driver status.
Signature:*

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Records Inquiry Release:
Date:*

MonthDayYear
Date
Social Security Number*
Name*

First NameLast Name
I voluntarily hereby authorize the South Orangetown Ambulance Corps Membership Committee / Corps Officers and Directors, to make inquiries into all of my records, including but not limited to Criminal History, Driving Records, Arson, as well as Employment, Education, and Training history. I further authorize and give permission to the Corps to contact the refrences I designated in my application for membership to the South Orangetown Ambulance Corps. I understand that all information will be kept in strict confidence by the Corps and used for the purpose of my eligability and standing as an acceptable candidate for membership in the Corps and the services the Corps provides to the community.
Signature:*

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Should be Empty:

	Yes	No
Are you a citizen of the United States?
Have you ever been convicted of a felony?
Have you ever been a member of the US Armed Forces?
Were you ever dishonorably discharged from the US Armed Forces?
Have you ever been removed from membership in another EMS agency, fire department, fraternal organization, or service club?

	Yes	No
Have you ever been trained in CPR?
Are you certified in CPR?
Are you certified First Aid?
Are you a certified NYS First Responder?
Are you certified as a NYS EMT?
Are you a Nationally Registered EMT?
Are you a Nationally Registered Paramedic?

South Orangetown Ambulance Corps

Personal Information:

General Information:

Education:

Employment:

References:

Availability & Training:

Membership Agreement:

Federal Driver's Protection Act

Records Inquiry Release: