Membership Application

Membership Application
Personal Information
Legal Name*

First NameLast Name
Preferred Name
Pronouns
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Phone Carrier*

AT&TT-MobileVerizonOther
Uniform Size*
Emergency Contact
Emergency Contact Name*

First NameLast Name
Relation*
Emergency Contact Phone Number*
Please enter a valid phone number.
History
Have you ever been arrested?*

YesNo
Please explain:*
Have you ever been convicted of a crime?*

YesNo
Please explain:*
Do you have any physical or psychological conditions which would prevent or restrict you in the performance of your duties as a member of TVAC?*

YesNo
Please explain:*
Have you ever been a member of TVAC?*

YesNo
Please explain:*
Have you ever been a member of another ambulance agency?*

YesNo
Please explain and list other memberships:*
Have you ever applied to TVAC before?*

YesNo
Please explain:*
How did you hear about our department?*
References
Do you know any members of TVAC?*

YesNo
Please specify which members:*
Reference 1

Please list a reference (non-family member).
Reference 1 Name*

First NameLast Name
Relation*
Reference 1 Email*
example@example.com
Reference 2

Please list a reference (non-family member).
Reference 2 Name*

First NameLast Name
Relation*
Reference 2 Email*
example@example.com
Application Type

Please indicate the membership category being applied for.
For additional information and requirements on each membership category, please review the TVAC By-Laws and Standard Operating Procedures (SOPs).
Membership Category*

DriverEMREMT
Confirmation of Membership Requirements
I confirm that I meet the requirements for the membership category of Driver as outlined in the TVAC By-Laws.
I confirm that I*

am at least 21 years of agewill obtain an EMR/EMT certification within six months of membershipdo not have any suspensions or points on my driver's abstractam of good moral character and without any convictions and criminal offenses
Confirmation of Membership Requirements
I confirm that I meet the requirements for the membership category of Junior Member (EMR) as outlined in the TVAC By-Laws.
I confirm that I*

am at least 15 years of agewill obtain an EMT certification within nine months of joining TVAC or within nine months of my 16th birthday, whichever is lateram of good moral character and without any convictions and criminal offenses
Confirmation of Membership Requirements
I confirm that I meet the requirements for the membership category of Member (EMT) as outlined in the TVAC By-Laws.
I confirm that I*

Am at least 16 years of ageAm of good moral character and without any convictions and criminal offenses
EMT Certification Status
EMT Certification Status*

I currently hold an EMT CertificationI do not currently hold an EMT Certification but wish to apply to TVAC Membership to receive payment and sponsorship for an EMT Course
BLS CPR Certification

Please upload a valid, BLS CPR certification below. If you are not BLS CPR certified by a valid Training Agency, please email cpr@tenaflyambulance.com to schedule a course.
To view valid Training Agencies and Certifications, please visit:

https://www.nj.gov/health/ems/documents/CPR%20Approved%20Certifications%205_3_2024.pdf
BLS CPR Certification Expiration Date*

MonthDayYear
BLS CPR Certification Upload*

Cancelof
EMR Certification
EMR Certification Expiration Date

MonthDayYear
EMR Certification Upload

Cancelof
EMT Certification
NJEMS 6-Digit ID
NREMT EMS ID
EMT Certification Expiration Date

MonthDayYear
EMT Certification Upload

Cancelof
Driver's License Information
Driver's License Number
Driver's License Expiration Date

MonthDayYear
Driver's License (Front) Upload

Cancelof
Have you received any motor vehicle violations in the past year?

YesNo
Please explain:*
Certified Emergency Vehicle Operator (CEVO) Certification
To obtain a valid CEVO Certification, please visit:

https://coachingsystems.com/product/cevo-5-ambulance-evoc-training/
CEVO Certification Upload*

Cancelof
Medical Clearance
Please have your primary physician complete the following Medical Clearance Form.
Medical Clearance Upload*

Cancelof
COVID-19 Vaccination Upload*

Cancelof
Certification

Please complete and sign the below.
I, First Name* Last Name* , certify that all information on this application and any materials uploaded to be true. I grant permission to TVAC's Membership Committee to review this application and to contact the references provided to obtain any additional information deemed pertinent to membership. I grant permission to TVAC's Membership Committee to reproduce this page to the Tenafly Police Department for a background check to be completed.
Declaration

Please complete and sign the below.
I, First Name Last Name , herby apply for membership of the Tenafly Volunteer Ambulance Corps. I promise to abide by TVAC's Ordinance, By-Laws, and Standard Operating Procedures (SOPs) and Policy Manual. I pledge to serve under the direction of TVAC's duly elected.

I waive any claim for redress against TVAC for any personal injury or loss suffered as a result of any activity associated with membership accepting, in lieu of therefore, the protection provided by the insurance policy or policies carried and maintained by TVAC.

I agree that all property, uniform, and equipment loaned to me for use by TVAC are to be returned immediately upon my severance therefrom or upon demand.
Signature
Prospective Member Signature*

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Guardian Information and Signature

Please have a guardian complete and sign below if under 18 years old.
Name

First NameLast Name
Relationship
Guardian Signature

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Should be Empty:

Membership Application

Personal Information

Emergency Contact

History

References

Reference 1

Reference 2

Application Type

Confirmation of Membership Requirements

Confirmation of Membership Requirements

Confirmation of Membership Requirements

EMT Certification Status

BLS CPR Certification

EMR Certification

EMT Certification

Driver's License Information

Certified Emergency Vehicle Operator (CEVO) Certification

Medical Clearance

Certification

Declaration

Signature

Guardian Information and Signature