Please print and mail to:                                             Jeannette E.M.S., Inc.                                                         

 225 S. 6th Street

    Jeannette, PA  15644

Application for Volunteer Membership

18 years of age and over

Application Date________________

 

Name___________________________________________________________ Telephone Number_____________________

             Last                                                             First                                                MI

 

Address______________________________________________________________________________________________

 

City___________________________________________________State__________________ Zip_____________________

 

Age________________ Date of Birth_________________________ SS #_________________________________________

 

Eye Color__________________________________ Hair Color_________________________________________________

 

Marital Status (    )Single  (    )Married

 

Do you have any physical defects that we should know about? (    )Yes  (    )No, If yes, please explain___________________

 

Occupation_________________________________________ Employer__________________________________________

 

Employers Address_____________________________________________________________________________________

Do you have a valid drivers license? (    )Yes  (    )No, If yes what state is it issued____________

Operators Number_______________________________________ Do you have any driving violations (    )yes  (    )No

If you do have driving violations, please explain______________________________________________________________

 

Before driving any vehicles owned and operated by Jeannette E.M.S., Inc., we require that you have a state certified E.V.O.C. course and we have the right to check your M.V.R.  Do you understand this?  (    )Yes  (    )No.

 

Do you understand that while in the membership of Jeannette E.M.S., Inc. and you receive any violations on your license you must notify the management of Jeannette E.M.S., Inc.? (    )Yes  (    )No

 

Have you ever been convicted of a crime? (    )Yes (    )No, If yes, please explain ___________________________________

 

____________________________________________________________________________________________________.

 

Have you ever served in the military?  (    )Yes (    )No, If yes, what branch________________________________________

 

Date of discharge______________________________ Are you in the reserves? (    )Yes (    )No

 

I understand that as a volunteer I will have contact with private and confidential patient information and for no reason will I discuss this information with any other persons outside this organization, not even family members nor will I release to any other person such as the media any information regarding any patient or patient condition and will refer all such matters to the management of Jeannette E.M.S., Inc. (    ) Yes (    )No,  Please Initial Here_________________________

First Aid Training

 

TRAINING TYPE	STATE ID NUMBER	EXPIRATION DATE
C.P.R.	FFFFFFFFFFFFFFFFFFFFFFFFFFFFF
(   )EMT   (    )Paramedic  (    )H.P.
Other________________________

 

If you are a Paramedic, do you have medical command? (    )Yes (    )No.

 

Why do you want to join this organization? _________________________________________________________________.

 

____________________________________________________________________________________________________.

 

REFERENCES:  Please list three references not related to you and only one (1) may be an employee or a volunteer of this organization.

NAME	ADDRESS	TELEPHONE	YEARS KNOWN

ATTACH TO THIS APPLICATION ONE PHOTOGRAPH OF YOURSELF. If a photograph is not attached the application is not considered complete and will be returned to you for completion.

I certify that all the information on this application is true and correct to the best of my knowledge.  I hereby give the Jeannette E.M.S., Inc. my permission to investigate this application.  I also agree that I am on a 1-year probationary period and may be discharged without cause at anytime during this probationary period. I understand and agree that I will return to Jeannette E.M.S., Inc. any equipment and uniforms issued to me up request of management.

Signature____________________________________________________________ Date____________________________

  DO NOT WRITE BELOW THIS LINE

Police Report_________________________________________________________________________________________

Date Interviewed__________________________________ Interviewed by________________________________________

Interview Results

Application found (    ) Favorable  (    )Non-Favorable Date_______________________________________

Chairman_____________________________________________ JEMS ID Number ________________________________

Letter Sent_________________________________________