Volunteer Application

Contact Information
Name
Street Address
City, ST, ZIP Code
Telephone Number
E-Mail Address
Date of Birth
Social Security Number
Driver License Number	Expiration:
Availability
During which hours are you available for volunteer assignments?
Weekday mornings	Weekend mornings
Weekday afternoons	Weekend afternoons
Weekday evenings	Weekend evenings
Employment

Are you currently employed	YES	NO
May we contact your workplace for a reference?	YES	NO

Name of Employer

Street Address

City, ST, ZIP Code

Telephone Phone

E-Mail Address

Person to Notify in Case of Emergency

Name

Street Address

City, ST, ZIP Code

Home Phone

Work Phone

E-Mail Address

Education
High School		Year Graduated
College		Year(s) attended
Degree
CPR Certified	YES NO	Expires
EMT Basic/IV Tech	YES NO	Expires
EVOC	YES NO	Year of initial course
Other
References
Full Name
Contact Information
Full Name
Contact Information

Agreement and Signature

By submitting this application, I affirm to the Brooklyn EMS that the facts set forth in it are true and complete. In applying for the position of EMT DRIVER (circle one/both) consent to and authorize release and disclosure of information relative to identity, driving records, criminal records, and/or work records that are pertinent to my acceptance as a member of the Brooklyn EMS and my ability to serve as a licensed Emergency Medical Technician or Driver.

Name (printed)

Signature

Date

Our Policy

Membership in the Brooklyn EMS is based on the acceptance and approval of a prospective member by the Executive Board of Service. The Board reserves the right to accept or reject any application for membership. If approved by the Executive Board, then the membership will vote on final approval or rejection. Any false statements, omissions, or other misrepresentations made on this application may result in the immediate dismissal of the prospective member.

Thank you for completing this application form and for your interest in volunteering with Brooklyn EMS.

_______________________________________________________________________________________

For Executive Board use only: ACCEPTED YES NO

DENIED YES NO

Reason for denial:

_____________________________________________________________________________________________________________

Return application to: Director of Brooklyn EMS

401 W. Main Street

P.O. Box 248

Brooklyn, WI 53521