Download BATH AMULANCE - BathAmbulance

110 East Steuben Street Bath, NY 14810 Phone: (607)776-3156 Fax: (607)776-8475 Email: [email protected]
APPLICATION FOR VOLUNTEER
BATH AMULANCE
Thank you for your interest in volunteering here at Bath Ambulance!
WHO ARE WE
Bath Ambulance is the only volunteer ambulance agency in Steuben County that is
staffed 24 hours a day, 7 days a week, and 365 days a year. The staff consists of trained
Emergency Medical Technicians and CPR/AED, Basic First Aid certified drivers from Steuben,
Schuyler, Chemung and surrounding areas. We occasionally respond with the Rural Metro fly
car when advance life support is needed. Our mission is to provide excellent pre-hospital care
with professionalism, dedication, integrity and dignity to the community.
WHAT WE OFFER
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Many free training opportunities offered.
Hands on experience
A chance to work alongside medical professionals
Use of facility while on duty. Our facility has a full kitchen, lounge area that includes
cable and flat screen TV, computers with internet connections, two bedrooms, meeting
room, and a garage that houses three ambulances.
Uniforms
Monthly incentives to members who help out doing second calls, transfers and attend
monthly membership meetings.
An annual dinner dance at which we recognize members who have been outstanding
volunteers throughout the year.
REQUIREMENTS FOR VOLUNTEERING
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All applicants must pass a criminal and driving background check
Must be a minimum age of 19 years with a minimum of two years driving experience.
Have a valid New York driver license with no class A or less than two class B violations.
Must be certified in CPR/AED and Basic First Aid (training will be offered).
Must be able to work with the general public
Applicants who wish to volunteer as an EMT must be currently certified as an EMT-B,
EMT-I, EMT-CC or EMT-P.
WHAT IS EXPECTED OF OUR VOLUNTEERS
Volunteers are required to volunteer at least 12 hours a month and to attend at least 5
membership meetings throughout the year. We expect our volunteers to act professional at all
times and to be in approved uniforms while on duty. Volunteers are asked to maintain living
quarters and ambulances. Volunteers must be able to work with diverse personalities.
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110 East Steuben Street Bath, NY 14810 Phone: (607)776-3156 Fax: (607)776-8475 Email: [email protected]
BATH AMULANCE
APPLICATION FOR VOLUNTEER
Name:
Date:
Last
First
Middle Initial
Present Address:
Number
Phone: (
)
Street
City
Cell Phone: (
Date of Birth:
)
State
Zip
Email:
Social Security Number:
Are you a US Citizen?
YES
NO
Have you ever volunteered here before?
If so, when?
YES
NO
Reason for leaving:
Do you have any friends or relatives that currently volunteer here?
If yes, whom?
YES
NO
How did you hear about our organization?
Have you ever been convicted of a violation of the law?
If yes, please describe:
YES
NO
Have you ever been convicted of any offense involving health care fraud or patient abuse?
If yes, please describe:
YES NO
FALSIFICATION AND OMISSIONS WILL RESULT IN DISQUALIFICATION.
Do you have a valid Driver License?
Class:
YES
NO
Issued by what State:
Driver License Number:
List all moving violations (convictions) and accidents and any suspensions or revocations of your license
in the last four years:
Have you ever been convicted, or pled guilty or no contest to a felony or misdemeanor, including a
DUI/DWI or similar offense, had any moving violations, or had your license revoked or suspended?
YES
NO
If yes, explain:
A conviction will not necessarily disqualify you from volunteering
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110 East Steuben Street Bath, NY 14810 Phone: (607)776-3156 Fax: (607)776-8475 Email: [email protected]
BATH AMULANCE
APPLICATION FOR VOLUNTEER
CERTIFICATIONS
PLEASE LIST ONLY CURRENT CERTIFICATIONS. PHOTOCOPIES NEED TO BE PROVIDED AT INTERVIEW.
Certification Number
Expirations Date
Certifying Agency
CRP/AED
Standard First Aid
Certified First Responder
EMT-Basic
EMT-Intermediate
EMT-Paramedic
Other
Employment History
1) Employer:
Address:
Phone #:
How Long?
2) Employer:
Address:
Phone #:
How Long?
3) Employer:
Address:
Phone #:
How Long?
Current Employer?
City:
State:
Supervisor:
Reason for leaving?
Current Employer?
City:
State:
Supervisor:
Reason for leaving?
Current Employer?
City:
State:
Supervisor:
Reason for leaving?
Yes
No
Zip Code:
Yes
No
Zip Code:
Yes
No
Zip Code:
EMS/FIRE/PROFESSIONAL AFFILIATIONS:
Please list any other experiences, skills or qualifications that may pertain to volunteering here:
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110 East Steuben Street Bath, NY 14810 Phone: (607)776-3156 Fax: (607)776-8475 Email: [email protected]
BATH AMULANCE
APPLICATION FOR VOLUNTEER
EDUCATION
HIGH SCHOOL
Name:
Address:
Did you graduate?
YES
Have you received your GED?
NO
YES
Name:
Address:
Did you graduate?
COLLEGE/VOCATIONAL SCHOOL/OTHER
Degree:
Major:
NO
YES
NO
Personal References
List three persons that have known you for at least three years.
Name
Address
Phone
Years Known
1)
2)
3)
Availability
Please list hours of availability
TUESDAY
WEDNESDAY
THURSDAY
SUNDAY
MONDAY
DAY
DAY
DAY
DAY
NIGHT
NIGHT
NIGHT
NIGHT
FRIDAY
SATURDAY
DAY
DAY
DAY
NIGHT
NIGHT
NIGHT
It is the policy of the Volunteer Ambulance Cops of Bath New York (“Bath Ambulance”), to provide equal
opportunity without regard to race, color, national origin, creed, sex, sexual orientation, age, disability, marital
status, and other reasons prohibited by law. In signing this application, I affirm that to the best of my knowledge
all statements on this application are true and complete without omission of any kind.
Signature:
Date:
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110 East Steuben Street Bath, NY 14810 Phone: (607)776-3156 Fax: (607)776-8475 Email: [email protected]
APPLICATION FOR VOLUNTEER
BATH AMULANCE
AUTHORITY FOR RELEASE OF INFORMATION
Police Chief
David R. Rouse
Phone: 607-776-2175
To Whom It May Concern:
I authorize any authorized person of the village of Bath Police Department, the Steuben County
Sheriff’s Department, of the New York State Police bearing this release to obtain any information from
schools, employers, criminal justice agencies, residential management agent or individuals relating to
my activities.
This information may include but not limited to: academic, residential, achievement,
performance, attendance, personnel history, disciplinary, arrest and conviction records. I hereby
authorize any authorized person to release such information upon request to the bearer. I understand
that the information released is for the official use by the Village of Bath Police and the Volunteer
Ambulance Corps of Bath NY and may be disclosed in the fulfillment of official responsibilities.
I release any individual, including record custodians from any and all liability for damages of
whatever kind in nature, which may result of compliance or any attempts to comply with this
authorization. Should there be any question as to the validity of this release, you may contact me as
indicated below.
Signature:
Full Name Printed:
Current Address:
City:
Date of Birth:
Driver License Number:
Day Time Phone:
Date:
State:
Postal Code:
Social Security Number:
Maiden Name (if applicable):
Evening Phone:
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110 East Steuben Street Bath, NY 14810 Phone: (607)776-3156 Fax: (607)776-8475 Email: [email protected]
BATH AMULANCE
APPLICATION FOR VOLUNTEER
Annual Medical Statement OF Personnel
This form is optional, though it is strongly recommended for all personnel to complete form. This form is
designed to provide the individual in charge of all personnel, a complete history of physical status as of
the date indicated without the need for expensive physical examinations. It is recommended that this
form be completed on an annual basis. If any question is answered ‘Yes’ be sure the answer is fully
explained under ‘Remarks’.
Name:
Date:
Last
First
Middle Initial
Present Address:
Number
Phone: (
)
Social Security Number:
Full Time Occupations:
Name of Organization:
Street
Cell Phone: (
City
)
State
Zip
Date of Birth:
Position/Title:
QUESTIONS:
Remarks:
NOTE: IF ANY QUESTION IS ANSWERED ‘YES’, PLEASE GIVE PARTICULARS UNDER ‘REMARKS’.
Note: For medical histories, identify by
referring to question number and letter.
Please give dates, symptoms, duration,
treatment results, names and addresses of
doctors, hospitals, etc.
1: EYESIGHT:
A: Have you lost use of either eye?
Right
B: Is peripheral (side) vision restricted?
C: Are you color blind?
D: Do you have, or have you ever had, cataracts?
E: Are actual deficiencies corrected by glasses or contact lenses?
F: Date of last eye examination:
2: HEARING:
A: Do you have difficulty hearing normal conversation level?
B: Do you use a hearing aid?
3: DIABETES:
A: Have you ever been treated for diabetes?
B: Describe current medication and dosage, if any and method
of administration under ‘remarks’.
C: Date of latest blood sugar test:
4: HEART:
A: Have you ever been treated for heart disease?
B: Describe condition under ‘remarks’.
C: Describe current medication and dosage, if any, under ‘remarks’.
D: Do you have a pacemaker?
E: Date of last treatment or check-up:
5: EPILEPSY:
A: Have you ever been treated for epilepsy?
B: If “Yes,” when was your last seizure?
C: Describe current medications and dosage, if any, under ‘remarks’
Left
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
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110 East Steuben Street Bath, NY 14810 Phone: (607)776-3156 Fax: (607)776-8475 Email: [email protected]
BATH AMULANCE
APPLICATION FOR VOLUNTEER
Remarks:
6: Blood Pressure:
A: Have you ever been treated for high blood pressure?
B: If “Yes,” when were you treated?
C: What was your last reading?
D: Describe current medication and dosage, if any, under ‘remarks’
Yes
No
Yes
Yes
Yes
No
No
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
11: Are there any restrictions posted on your vehicle operator’s license?
Yes
No
12: Are you under the care of a physician for any condition not mentioned
above which may affect your ability to operate a motor vehicle?
Yes
No
7: Limbs:
A: Have you lost an arm or leg?
B: Have you lost the use of an arm or leg?
C: Does vehicle have special controls?
D: If “Yes,” to any of the above, describe under ‘remarks’
8: Miscellaneous:
A: Have you ever had, or been treated for, Convulsions?
B: If “Yes,” give date of last treatment and describe current
medications and dosage, if any, under ‘remarks’
C: Have you ever had any Fainting Spells?
D: If “Yes,” give date of last treatment and describe current
medications and dosage, if any, under ‘remarks’
E: Have you ever had, or been treated for, Loss of Equilibrium?
F: If “Yes,” give date of last treatment and describe current
medications and dosage, if any, under ‘remarks’
G: Have you ever been treated for Alcohol or Drug Abuse?
H: If “Yes,” give date of last treatment and describe current
medications and dosage, if any, under ‘remarks’
I: Have you ever been treated for Mental Illness?
J: If “Yes,” give date of last treatment and describe current
medications and dosage, if any, under ‘remarks’
10: What is the date of your last physical examinations?
13: When and for what purpose, did you last consult a doctor?
14: Full Name, address, and telephone number of your personal physician.
Name:
Address:
City & State:
Zip:
Phone Number:
The answers to the above are complete, accurate, and true to the best of my knowledge.
Signature of Person Named Above
Date
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