Join The Team Join The TeamApply Online Or, download a printable application here Name Address Date of Birth Home Phone Work Phone Email Address Vermont Drivers License # Emergency Contact Name Emergency Contact Phone # Prior Relevant Training Other Current Service Affiliations (Fire, Scouts, Service Orgs, etc.) Current Certifications Type, ID or License #, and Expiration Date Identify any physical limitations that might limit what you can do (Heart, back problems, other limiting illnesses or conditions.) Personal Reference #1 Name, Address, and Phone Number Personal Reference #2 Name, Address, and Phone Number Professional Reference Name, Address, and Phone Number Do you have a current valid Vermont Drivers' License? Yes No Have you ever been convicted of a DWI? No Yes Are you willing to take additional training with the squad? Yes No Full membership in Waterbury Ambulance Service, Inc., is determined by vote of the squad after a candidate has served for at least six months. I certify that the facts given on this application are correct and true, to the best of my knowledge. I have withheld nothing that, if disclosed, could affect this application. I understand that if Waterbury Ambulance Service, Inc., approves my application, any false statements in this application are grounds for dismissal. I understand that membership requires the responsibility of filling a minimum of five 12 hour shifts per month. I agree to be available as scheduled unless I have been excused from this minimum. I understand that, while the squad will by to accommodate my needs, I may not be assigned to my choice of shifts. I further understand that participation on the squad requires me to act professionally and courteously toward patients and other squad members. If accepted for membership, I agree to follow all the Waterbury Ambulance Service, Inc., procedures, policies, and protocols, to the best of my ability. All applicants must certify to these statements, which are a condition of membership. Signature By typing your full name here, you are digitally signing this application and have agreed to the above disclaimers and conditions. Date Apply Now