Join The Team

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?

Have you ever been convicted of a DWI?

Are you willing to take additional training with the squad?

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

Address: