2024 Throggs Neck Volunteer Ambulance Corps Member Application

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Thank you for your interest in becoming a member of the Throggs Neck Volunteer Ambulance Corps. Please complete the form below or come to the base during an open tour. Someone will contact you for an interview. We look forward to meeting with you soon.

Email *

Name: *

Address: *

Cell Phone Number: *

Work Phone Number: *

Date of Birth:

YYYY

How did you learn about us? (Check all that apply) *

Friend/Relative/Member-Name:__________________________________________

Website/Social Media: Which one?______________________________________________________

Newspaper article or ad

Walk-In/Drive by

Radio or TV Announcement

School/Church

Community Event

Saw Crew in action

Other:

Required

I would like to work for Throggs Neck Volunteer Ambulance Corps in the following positions: *

Crew Chief

Ambulance Attendant

Motor Vehicle Operator

Dispatcher

Youth Corps Advisor

Administrative

Board Member (Please also submit a resume TNVACChairperson@gmail.com)

Required

Highest level of education: *

Middle School

High School Diploma/TASC/GED

Some College

Associate's Degree

Bachelor's Degree

Master's Degree

PhD, JD, MD

Other:

Have you ever been a member of TNVAC before? *

Yes

Other:

If you were a member, when was the last time you volunteered and why did you leave?

Have you ever been a volunteer at any ambulance corps before? *

Yes

Include all previous VAC and/or EMS experience in the following questions below. Write "no experience" below if you do not have previous experience. *

Do you have any paid EMS or Medical Industry experience? *

Yes

If so, please list the positions you have held and the names of the agencies/organizations you have worked with?

Please list all EMS/VAC Organization Names, Addresses, Positions Held, and dates when volunteered for your prior VAC experiences. Write "NONE" if you have not volunteered before. *

Are you a Certified EMT-B, EMT-A, or EMT-P? *

Yes (Answer all questions below)

No (Skip EMT certification questions)

I am no an EMT, but am interested in training to become one.

Month and Year of Your First EMT Certification?

Have you had your certification lapse or become terminated since it was issued for any reason?

Yes (Please explain:_______________________________________________________________)

Other:

Clear selection

NYS Paramedic Certification # & Expiration Date:

NYS EMT Certification # & Expiration Date:

Are you CPR Certified? *

Yes

No, but I would like to get certified

If you are CPR Certified, what is the name of the company you received your certification from and the certification number?:

When does your CPR Certification expire?

YYYY

Do you have a First Aid Certification? *

Yes, Basic First Aid

Yes, Advanced First Aid

No, but I would like to be.

What is the company you received your certification from and what is the certification number?

When does your Advanced First Aid certification expire?

YYYY

What company issued your certification in standard first aid and what is the certification number?

Do you have a valid Driver License? *

Yes

NYS DMV license number & expiration date:

Emergency Contact Name: *

Emergency Contact Phone Number: *

Emergency Contact Address: *

Relationship to Emergency Contact: *

Emergency Contact Email: *

Medical History: Do you have any physical, mental, or medical conditions which may interfere with your ability to perform the duties of the position(s) for which you have applied? *

Yes

If you answered yes to the above, please explain:

Do you have any allergies to food, medicine, environment, etc.? *

Yes

If you answered yes, please indicate what you are allergic to and if you need to carry an epipen below:

Legal History: Have you ever been convicted or a felony in any jurisdiction? *

Yes

If you have been convicted of a felony, please provide a detailed explanation below:

Have you, within the past three years, been convicted of any VTL felonies, misdemeanors, or moving violations? (MVO candidates MUST answer.) *

Yes

I do not want to become a Motor Vehicle Operator.

Other:

If yes, please explain:

Do you currently have any points against your license? (MVO candidates MUST answer.) *

Yes

I do not want to become a Motor Vehicle Operator.

Other:

If yes, please explain:

Have you been involved in any motor vehicle accidents within the last three years? (MVO candidates MUST answer.) *

Yes

I do not want to become a Motor Vehicle Operator.

Other:

If chosen to be a Youth Corps Advisor, would you be able to obtain a background check and complete our mandated reporter certification? *

Yes

I am not interested in becoming a Youth Corps Advisor

Please provide the name, relationship, and contact information (phone/email) for one reference below: *

Please provide a brief personal history. Include whatever you would like us to know about yourself including education, work, and interests. *

By submitting and agreeing to the statements below, you are requesting membership in Throggs Neck Volunteer Ambulance Corps and agree to the following: (Check to agree) *

I request membership in Throggs Neck Volunteer Ambulance Corps.

I agree that I have asked for and received answers to all questions necessary to enable me to understand the good faith commitment I am making, and if granted membership, I agree to abide by the specific obligations noted below as well as the by-laws and operating procedures of Throggs Neck Volunteer Ambulance Corps.

I agree to sign up for and work in a qualifying capacity a minimum of two scheduled tours per month.

I agree to attend monthly meetings as announced as well as the annual meeting, usually held in June.

I agree to complete all necessary training and testing for the position(s) I seek in a timely manner.

Provided I meet these I obligations for a period of one year, I understand I will be considered an active member in good standing.

I understand that a temporary inability to meet the tour, special event, or training obligations due to illness, vacation, work or any other reason must be documented in writing.

I agree to provide any supporting documentation requested in connection with a request for a leave of absence (LOA) should I request one.

I understand that upon recommendation of the Chief of Operations and with approval of the Board of Directors, active members in good standing will be considered for sponsorship in an approved EMT or recertification course.

I further understand that it is the practice of the Corps to offer its services to members and their immediate family members provided the request for service falls within our Primary Response Area.

I understand that as an organization providing emergent care, TNVAC is required by law and rules to collect certain health information such as records of vaccinations from its members.

I agree to provide such documentation as described above upon request.

I understand that as an entity involved in the care and transportation of patients, TNVAC is required by NYS Executive Law Sec. 836-s, to check the identifying information provided by all candidates against the NYS Sex Offender Registry. Eligibility for membership will then be determined pursuant to Correction Law Article 23-A.

I understand that and give permission for Throggs Neck Volunteer Ambulance Corps to contact references provided and confirm status of my experience, medical licenses and certifications.

If I selected motor vehicle operator (MVO)as a position above, I understand that and give permission for TNVAC to run a driver license check and, once I am an MVO, periodically check the status of my driver's license.

I understand that it is the responsiblitiy of the member to update TNVAC of any changes to my contact information and my medical licenses and/or certifications.

I agree to allow TNVAC to use my personal image and name on social media, newspapers, websites, or other promotional or informational material. If I do not want my image shared or used, I agree to provide TNVAC, in writing, my desire to refrain from having my image or personal name used for any reason.

I understand that I may be required to lift at least 125lbs and perform other physical tasks in order to obtain clearance for positions that include riding on the ambulance.

I understand that I will be a probationary member for a period of at least ninety (90) days and that my membership can be extended or terminated for cause at any time during that probationary period.

If you agree to all of the above and have checked all of the boxes, please type your name with the symbol "/s/" (EXAMPLE: /s/ John Doe)before your first name in the "other" option below to signify that you agree the following and are submitting your application. (You will be required to sign an application during your interview)

Other:

Required

Date Submitted:

YYYY

A copy of your responses will be emailed to the address you provided.

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