Please fill in each
of the following fields and click "Submit" when complete. Please note that all fields
are required to be completed.
Any Questions? Please call
the Captain's eMail: Captain@LewisboroVAC.org
Your Name
Your Address
Your eMail
Home Phone
Business Phone
Cell Phone
Date of Birth
Gender
Occupation
- Have you had any First Aid,
CPR, or other healthcare training? Yes No
- If Yes, please explain:
If you have any current certifications,
please list the type of certification, expiration date and ID#:
- Certification
- Expiration Date
- ID#
-
- Certification
- Expiration Date
- ID#
Although not a requirement,
would you be interested in furthering your medical training and
becoming a New York State Certified Emergency Medical Technician
(EMT)? Yes No
You are required to complete
the American Heart Association CPR and First Aid courses for
Healthcare Providers prior to riding with a duty crew. Our instructors
will provide you with the required initial and ongoing training.
These certifications must be maintained in order to remain active
in riding status and to participate in LVAC functions.
List people you know who are
currently members of LVAC:
- Member
- Member
- Member
- Member
REFERENCES: List three people
we may contact as a reference (other than relatives or family
members), preferably from an organization you belong or have
belonged to:
- Name Phone eMail
- Relationship
-
- Name Phone eMail
- Relationship
-
- Name Phone eMail
- Relationship
What are your hobbies or personal
interests?
-
Briefly explain why you chose
to apply for membership in the Corps:
Have you ever been a member
of any local, civic, church, or other volunteer organizations?
Please list the times and
days you anticipate being available to volunteer:
Commitments
of the Riding Member include, but are not limited to:
- - All riding members
must attend Tuesday night meetings and training drills at 7:30
pm in accordance with the by-laws of the Lewisboro Volunteer
Ambulance Corps.
- A minimum of 48 riding hours per month.
- All riding members are required to participate in
Corps functions and assist with administrative responsibilities.
- All riding members are required to attend an Ambulance
Orientation and a Policies and Procedures Orientation with an
appointed officer, and must be familiar with such, before they
are permitted to ride with a duty crew.
- All Riding members must provide annual proof of
vaccination status (flu, COVID-19, and PPD testing).
As a riding member of LVAC, it may be necessary to perform a variety
of tasks during the course of a typical emergency call, including
walking on rough or uneven ground, gripping with both hands,
climbing stairs, kneeling, crouching, lifting and running a short
distance. Do you have any physical disabilities or limitations
which would prevent you from participating in any of the above
activities? Yes No
If yes, please explain:
At any time have you ever
suffered from or experienced symptoms of: Chronic back pain,
sciatica or other disorder of the back, neck or spine; near fainting
or fainting episodes, vertigo or seizures? Yes
No
If yes, please explain:
Do you have any other medical
conditions or symptoms
not mentioned above or do you take any medication which
would make it difficult or dangerous for you to drive, operate
equipment or ride on the ambulance?
Yes
No
If yes, please explain:
- Have you had a full physical
exam in the last year? Yes No
- If Yes, date of physical:
-
- Have you been screened for
Tuberulosis in the past year? Yes No
- (If No, you will be required
to be screened prior to riding any shift.)
Have you ever been convicted
of a crime? Yes No
If yes, please explain:
Have you ever suffered from
or been treated for alcohol or drug abuse?
Yes No
If yes, please explain:
* * * * *
The above information is for
use solely by the Board of Directors of the Lewisboro Volunteer
Ambulance Corps in assessment of an applicant's eligibility for
membership as well as their ability to undertake the tasks necessary
to be a riding member. Answering yes to any of the above questions
does not necessarily disqualify you from being accepted as a
riding member of the Corps. If deemed appropriate, you may be
required to provide a physician's statement confirming your ability
to perform necessary tasks in a safe and effective manner. This
information is considered confidential and will not be shared
with the general membership or any outside agency, but will be
retained by the Corps as part of your personnel file.
* * * * * *
The information I have provided
in this application is true and accurate to the best of my knowledge.
I understand that any false information shall be reason for my
immediate dismissal from the Lewisboro Volunteer Ambulance Corps.
I also agree that, if accepted by the membership, I will, at
all times, obey the by-laws, operating rules and policies of
the organization and perform in an appropriate manner which is
beneficial to the Corps. (By completing your name and the
date, you are signing the application.)
Signed:
Date:
PLEASE
REMEMBER TO CLICK THE "SUBMIT" BUTTON BELOW TO PROCESS
YOUR APPLICATION!
|