Brewerton Volunteer Fire Department Ambulance
EMT - Application
Brewerton Volunteer Fire Department Ambulance Application
EMT - Position
Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Languages fluently spoken in addition to English
Are you a licensed medical professional?
Yes
No
What is your certification number?
Other
Professional Reference
First Name
Last Name
Reference phone number
Format: (000) 000-0000.
Professional Reference
First Name
Last Name
Reference phone number
Format: (000) 000-0000.
Professional Reference
First Name
Last Name
Reference phone number
Format: (000) 000-0000.
Type of Provider
Please Select
Physician
Physician Assistant
Nurse Practitioner
Registered Nurse
Licensed Practical Nurse
Certified Registered Nurse Anesthetist
Emergency Medical Technician
Respiratory Therapist
Certified Nurse Assistant
Social Worker
Pharmacist
Physical Therapist
Behavioral Health Provider
Dentist
Occupational Therapist
Please indicate highest level of patient care
Please Select
CPR/First Aid
EMT -
AEMT
EMT_CC
EMT- Paramedic
Work Status
Please Select
Actively practicing
Not actively practicing, but not retired
Retired
Matching with Need
Please indicate highest number of hours you are able to Volunteer in a day. Brewerton Ambulance requires a 12 hour volunteer shift a month.
Please Select
4
6
8
12
Other Information
Please indicate if you have any pre-existing conditions, especially any with COVID-19 increased risk
Yes
No
Other
Signature
Please upload a picture of your driver's license, EMT and CPR Cards
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