Williamsport Volunteer Ambulance Service

Volunteer Membership Application

Revised December 1, 2003

Today’s Date____________

Full Name: ___________________________

Birthdate: ____________ Sex: ____

Address: _____________________

_________________ ST _____ Zip ______

SSN: _______________

Contact Numbers:

Home: ____________ Work: ____________

Cell: ____________ Pager: ____________

E-mail address: ___________________________________

Emergency Contact Person & Relationship: _____________

Their Phone: _____________

Marital Status:____ Spouse’s Name _____________

Membership Type: (circle one or more of the categories below)

Operations Associate Affiliate (Youth, Auxiliary, Dive Team)

Have you ever made application with WVAS in the past?

Yes No

Please explain any physical limitations you may have.

________________________________________________

________________________________________________

List any medication allergies and reactions?

____________________________________________

List any Current Traffic Violations?

________________________________________________

Explain any criminal record you may have had.

________________________________________________

List any and all fire or rescue companies you have worked or volunteered for.

________________________________________________

List any special skills.

________________________________________________

Education

High School Attended: _____________________________

Did you graduate High School: Y N GED: Y N NA

College Attended: ________________________________

Special Courses: _________________________________

What equipment are you able to use?

________________________________________________

What are your goals during your membership with WVAS?

________________________________________________

________________________________________________

________________________________________________

________________________________________________.

What days, evenings, nights would be best for you to give time?

________________________________________________.

I, ____(print your name)_______________ authorize the Williamsport Volunteer Ambulance Service, Inc. to conduct a thorough and complete criminal and civil background investigation. I also authorize COPS, Inc., to release all information in writing regarding my investigation to the Williamsport Volunteer Ambulance Service, Inc.

___________________________ (Signature)

_____________________________ Date

_______________

Witness

Membership Agreement

I hereby affirm that all statements made herein are true and correct to the best of my knowledge. I authorize Williamsport Volunteer Ambulance Service to conduct whatever investigation deemed necessary to confirm statements submitted on this application. I understand that any false statements 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 they 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 bylaws, rules and regulations and the Standard Operating Guidelines of the Williamsport Volunteer Ambulance Service.

I agree to submit myself, upon request to a complete physical examination by a physician to be determined by Williamsport Volunteer Ambulance Service or Washington County Volunteer Fire and Rescue Association and understand that certain membership activities are subject to medical clearance.

I understand that the Williamsport Volunteer Ambulance Service will not discriminate against age, sex, religious belief, race, physical challenges, national origin or sexual orientation.

I understand that any and all information obtained by the Williamsport Volunteer

Ambulance Service will become part of my personnel file and will remain confidential.

I understand that if accepted into membership of the Williamsport Volunteer

Ambulance Service, 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 Williamsport Volunteer Ambulance Service 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 Williamsport Volunteer Ambulance Service, my membership will be at will and that my membership may at any time and for any reason be terminated by the Williamsport Volunteer Ambulance Service.

______________________________ ________________

Signature Date

______________________________ ________________

Witness Date

References

Please list three references not related to you.

Name ________________________________

Address ______________________________

City __________________ ST _____ ZIP _________

E-Mail ____________________________

Name ________________________________

Address ______________________________

City __________________ ST _____ ZIP _________

E-Mail ____________________________

Name ________________________________

Address ______________________________

City __________________ ST _____ ZIP _________

E-Mail ____________________________

Thank you for applying for volunteer membership with the Williamsport Volunteer Ambulance Service. You will be contacted by one of our Trustees for an interview. We’re looking forward to meeting you.