Volunteer Application - Updated 7/4/14

The HOPS EMS team consists entirely of volunteer emergency responders and includes EMT's, First Responders, Drivers (units), and Junior Members. HOPS encourages all individuals interested in volunteering as an emergency responders to apply. Individuals who are currently training may apply to be a unit pending successful completion of their certification course. Please print and complete the application below and mail or drop off the application with all required documentation to:

HOPS EMS
6185 Herrickville Road
Wyalusing, PA 18853

You may also email the application and required documentation to: hopsamb@epix.net
(Please indicate that this is a volunteer application in the subject line.)

*Please note that all applicants must attend at least one meeting prior to approval of their application. Meetings are held the first Wednesday of the month at the EMS garage. All applicants must consent to criminal and child abuse background checks. If you have had background checks completed within the past 12 months, please include a copy with your application. Please direct any membership questions to: Charlie Dull, Captain (570) 744-1566.


14

H.O.P.S. Ambulance Volunteer Application


DATE: ____________________________________

What position are you applying for: Medical / Junior Member / Driver

PERSONAL INFORMATION

Name: __________________________________________

Street Address: __________________________________

City, State, Zip: __________________________________

Previous Addresses within the past 10 years:

________________________________________________

________________________________________________

Home Phone: (____) ____ - ___________

Work Phone: (____) ____ - ___________

Social Security Number: ___________________________

Are you 18 years or older? YES / NO

Are you 16-17 years old? YES / NO (working papers required)

EMS HISTORY

Are you currently certified by Pennsylvania as an EMT-B, EMT-P, or First Responder (EMR?) YES / NO

If yes, please provide certification number: ____________________ Expiration Date: ___________

Are you currently certified in CPR? YES / NO

If yes, please what is the expiration date? __________________ Circle One: Basic / Healthcare Provider

Are you willing to take further training when available? YES / NO

Do you have any restrictions that limit our ability to perform the duties of the position applied for? YES / NO

Are you EVOC certified? YES / NO Date of Class: _____________________

Sponsor's Signature: ___________________________________________________

EDUCATION

Highest Level of Education Completed: _________________________________________

High School: ____________________________ Graduation Date: ____________ Major: __________

College: _______________________________ Graduation Date: ____________ Major: __________

Other: ________________________________ Graduation Date: ____________ Major: __________

EMPLOYMENT

Company Name: _____________________________________________________________________________

Address: _______________________________ City: ______________ State: _____ Zip: ______________

Supervisor: _________________________________________ Phone Number: (____) ____-______________

Job Title: ______________________________________ Dates Employed: ____________________________

Job Duties: _________________________________________________________________________________

Reason for leaving: __________________________________________________________________________


Company Name: _____________________________________________________________________________

Address: _______________________________ City: ______________ State: _____ Zip: ______________

Supervisor: _________________________________________ Phone Number: (____) ____-______________

Job Title: ______________________________________ Dates Employed: ____________________________

Job Duties: _________________________________________________________________________________

Reason for leaving: __________________________________________________________________________

FIELD EXPERIENCE

Please list all emergency services that you have been affiliated with, the dates of your affiliation, and the name
of your direct supervisor:

1. __________________________________________________________________________________________

2. __________________________________________________________________________________________

3. __________________________________________________________________________________________

4. __________________________________________________________________________________________


Please list any special positions held: ___________________________________________________________

____________________________________________________________________________________________

Please list any additional training or certifications you may have received:

1. __________________________________________________________________________________________

2. __________________________________________________________________________________________

3. __________________________________________________________________________________________

Have you been suspended or expelled from any organization: YES / NO

If yes, please explain: _________________________________________________________________________

OTHER INFORMATION

Do you have a driver's license in either PA or NY? YES / NO

License Number: ____________ Expiration: _______

Have you been convicted of or plead guilty to a felony by a civil or military authority? YES / NO

Have you been convicted of or plead guilty to a misdemeanor or summary offense
(including traffic violations) in the last five years? YES / NO

Do you use controlled drugs (non-OTC drugs) not prescribed by a physician? YES / NO

Please list any special skills:

1. __________________________________________________________________________________________

2. __________________________________________________________________________________________

3. __________________________________________________________________________________________

Please circle days you could be available:

Monday / Tuesday / Wednesday / Thursday / Friday / Saturday / Sunday

Times: ___________________________________________________________

REFERENCES

Please provide references from 3 persons who are not relatives or former employers whom you have known for at least one year:

1. Name: ___________________________________________ Phone: (____) ____ - _______________

2. Name: ___________________________________________ Phone: (____) ____ - _______________

3. Name: ___________________________________________ Phone: (____) ____ - _______________

VERIFICATION

I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO
THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS
ON THIS APPLICATION WILL BE GROUNDS FOR DISMISSAL.

I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND REFERENCES LISTED
ABOVE TO GIVE ANY AND ALL INFORMATION CONCERNING MY EMPLOYMENT HISTORY AND ANY
PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR
ANY DAMAGE THAT RESULTS FROM FURNISHING SAME TO H.O.P.S. EMS. I ALSO AUTHORIZE HOPS
EMS TO PERFORM A BACKGROUND CHECK TO VERIFY CRIMINAL AND CHILD ABUSE HISTORY.

SIGNATURE: _________________________________________________________________________

Copies of the following must be submitted with this application:

1. ________ Driver's License

2. ________ EVOC certification

3. ________ CPR certification

4. ________ EMT/FR certification

5. ________ Immunization records

JUNIOR MEMBER

Parent / Guardian signatures obtained? YES / NO

Working Permit obtained? YES / NO

Guidance counselor signature obtained? YES / NO

INVESTIGATION COMMITTEE FINDS THE APPLICANT: Favorable / Unfavorable

Committee Member Signatures:

____________________________________________________ Date: ______________

____________________________________________________ Date: ______________

____________________________________________________ Date: ______________

____________________________________________________ Date: ______________
Proudly powered by e107 which is released under the terms of the GNU GPL License.

'sebes' by jalist