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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 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 • • • • • • 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 • • • • • 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. 0 110 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 1 110 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: 2 110 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: 3 110 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: 4 110 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 5 110 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 6 Submit Via Email