Clone of Career Personnel Application

Volunteer Application

Boonsboro Ambulance & Rescue, Inc.
Membership Process

1. Your application will be given to a member of the Membership Committee.

2. You will be called to set up a time for an interview. If you have not included current certification cards with your application, please bring them with you to the interview.

3. Your application will be brought to the next membership meeting for a vote of membership.

4. Once brought on as a probationary member, you will have six (6) months for both you and Boonsboro Ambulance and Rescue to decide if this is a good choice.

5. Before riding on the units, you must have completed CPR certification, HIPAA training, Haz-Mat Operations training, and Bloodbourn Pathogens classes.

6. You will be expected to attend a general orientation class prior to riding on the units.

7. All of your references must be returned before you can become a full member.

8. As a probationary member, you are encouraged to attend as many company meetings and fundraisers as possible. You will NOT be able to vote on any issues at any meeting, though. This will familiarize you to the process and allow the other members to meet you.

If you have any questions or concerns, do not hesitation to ask any membership committee member or officer of the dept. Thank you for applying for membership with Boonsboro Ambulance and Rescue, Inc.
Administrative

Do not complete below this line.

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Types of Membership

Operational
1. Must be at least 16 years of age.

2. Must pull a combination of at least 16 hours a month or a cumulative of 180 hours in a calendar year.

3. Must have or receive a current EMT-B or higher certification within one (1) year of membership.

4. After six (6) months probation, may vote on all company issues.

Administrative
1. Must be at least 18 years of age.

2. Must attend at least 8 meeding in a calendar year.

3. Must assist the company by working a minimum of fifty (50) hours of fundraisers a year.

4. After six (6) months probation, may vote on all company issues.

Junior
1. 14-16 years of age.

2. Must assist with the majority of fundraisers.

3. Can attend company meetings, but will not be allowed to vote on any company issue.

4. Must complete all orientations and initial trainings.

Associate
1. Any person who is not active, lifetime, or probationary who will assist the company with various activities on a regular basis.

2. Associate members will have no voting privileges in the company nor will hold any keys to any company property.

Membership Type Applying for
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameMiddle InitialLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security
Address

Street Address

Street Address Line 2

CityState

Zip Code
City of Birth
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Contact Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Driving Record
Driver's License Number
Issuing State
Class of License
If you checked any of the boxes in the above selections, explain the circumstances below:

References
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years Known:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years Known:
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Years Known:
Do you know an employee/member of Boonsboro Ambulance & Rescue?
How did you hear abour Boonsboro Ambulance & Rescue?

Employment History

Complete the information for your current job.
Employer # 1
Address

Street Address

Street Address Line 2

CityState

Zip Code
Position/Title
Job Description
Employed From

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Employed To

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Leaving
Supervisor Name & Phone Number

Education

Rows	Location	Name	Years Completed	Diploma/Degree
High School
College/University
Trade/Technical

If you did not graduate from high school, have you passed and received a high school equivalancy certificate fro the stae of Maryland or any other states?
Name the state granting certificate of equivalency
Date of Issuance

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
MFRI/Specialized Training
Military Service
Are you a veteran?
Branch
Rank
Dates of Enlistment
Specialty

Medical History

The duties of the position at Boonsboro Ambulance & Rescue are strenuous, enplanned, and mentally as well as physically stressing. You must be able to perform the duties of the position in all types of weather, in stressful situations, and at all hours of the day.
Family Physician
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
List any other physicians or specialists (and phone numbers) you are currently under their care. List any additional impairment whic could affect your performance.
If you have any medical, physical, or emotional limitations, please explain

Department Information
Have you ever applied for membership at Boonsboro Ambulance & Rescue?
Have you ever been a member of Boonsboro Ambulance & Rescue?
If yes to the 2 above questions, why were you not voted in, or why did you leave?
Have you been, or are you now, a member of another ambulance service, rescue unit, or fire department? List the departments.
Have you ever been suspended, rejected, or denied membership from any other ambulance services, rescue units, or fire departments?
If so, please explain.
Do you, or have you ever held a certification for any special training relating to emergency care or rescue? Please list any and attach copies of these at the end of the application.
What do you hope to accomplish by becoming a volunteer member?

Membership Agreement

I hereby affirm that all statements made herein are true and correct to the best of my knowledge. I authorize Boonsboro Ambulance and Rescue Service, Inc. to conduct whatever investigation deemed necessary to confrim statments submitted on this application. I understand that any flase statments are sufficient grounds for immediate termination or rejection of this application.

I authorize all references listed in this application to give any and all information that thye have, and release all parties from liability for any damage that may result from furnishing this information to you.

I agree to fully abide by the By-Laws, Rules and Regulations, and the Standard Operating Guidelines (SOGs) of the Boonsboro Ambulance and Rescue, Inc.

I agree to submit myself, upon request to a complete physical examination by a physician to be determined by Boonsboro Ambulance and Rescue Service, Inc. or Washington County Volunteer Fire and Rescue Association, or Washington County Department of Emergency Services and understand that certain membership activites are subject to medical clearance.

I understand that Boonsboro Ambulance and Rescue Service, Inc. will not discriminate against age, sex, religious beliefs, race, physical challlenges, nationality, or sexual orientation.

I understand that any and all information obtained by the Boonsboro Ambulance and Rescue Service, Inc. will becomes part of my personnel file and will remain confidential.

I understand that if accepted into membership of the Boonsboro Ambulance and Rescue Service, Inc, I may at any time and for any reason terminate my membership.

I understand that nothing contained in this application is intended to create a member`s contract between the Boonsboro Ambulance and Rescue Service, Inc and myself for either membership or the providing of any benefit. No promises have been made to me regarding membership. I understand that if accepted into membership of the Boonsboro Ambulance and Rescue Service, Inc., my membership will be at will and that my membership may at any time and for any reason be terminated by the Boonsboro Ambulance and Rescue Service, Inc.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Volunteer Application

Administrative

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Emergency Contact

Driving Record

Background Information

References

Employment History

Education

Military Service

Medical History

Department Information