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GLEN ROCK VOLUNTEER AMBULANCE CORPS

Membership Application
Glen Rock Volunteer Ambulance Corps
700 South Maple Avenue, Glen Rock, NJ
Phone: 201-444-9795

* Indicates required field

First Name *

Last Name *

Sex *

Male Female

Date *

Date of Birth *

Soc Sec # *

Street Address *

City *

New Jersey

Zip Code *

Mobile Phone *

Home Phone *

Email *

Occupation *

Employer *

School You Are Attending *

Current Status *

Grad Date *

Emergency Contact *

Relationship *

phone *

If You Have Served On An Ambulance Corps, Which One? *

Years Experience *

Last Served *

6 Digit EMS # *

All Prospective Members must undergo a physical examination by the GRVAC doctor to determine the member’s physical and mental fitness for the position. The cost for this physical will be covered by the GRVAC. If you currently have or have had any physical or mental illness, it may affect your performance as an EMT. If you have or have had any physical or mental illness, you must supply our corps physician with a release from your caring physician at the time of your physical examination stating that you can perform the duties as an EMT. Please Initial *

I understand that by signing this application, a criminal background check will be arranged by the training academy to verify my background. A criminal record will most likely prohibit an applicant from performing the hospital observation requirement of EMT training and from taking the NJ State certification examination. Without either, the applicant will not be eligible for state certification and the pending membership to the GRVAC will be terminated. Please Initial *

Have you ever been convicted of any crime, or any offense other than a motor vehicle violation? *

Yes No

If Yes, please state the particulars *

Valid NJ Drivers License Number *

Expires *

Please list any resrictions on your drivers license. *

Has your driving privilege ever been denied, revoked, or suspended in this or any other state? *

Yes No

If yes, please state particulars *

Following successful completion of EMS training and NJ State Certification, you will become a probationary/active member of the GRVAC. Responsibilities of probationary/active membership include the following: It is expected that the probationary period will last from six to twelve months. Completion of all required GRVAC training. Serving on the duty roster for at least one scheduled shift per week and one scheduled weekend shift per month during the 12 month probationary/active member period. Regular attendance of the monthly Chief’s Drill and Business Meeting. Please Initial *

I hereby apply for pending membership in the Glen Rock Volunteer Ambulance Corps, Inc. If accepted, I promise to abide by the Rules Regulations, and Bylaws of the GRVAC. I understand that this application does not constitute acceptance of membership, but my acceptance will be subject to a review of the information I have provided here and any information resulting from my physical, driving and background investigations. I declare that I know the contents of this application, and certify the contents herein to be true. I fully understand that any misstatement or misrepresentation of fact, and/or the withholding of any information whatsoever may result in the denial of this application or dismissal from the GRVAC. Please Initial *

I further understand and agree that it is my continuing obligation if accepted as a member to inform the GRVAC Executive Board of any occurrences during my membership which would affect or change the answers to the above questions. Please Initial *

I also understand that I will be held responsible to return any equipment or supplies that will be provided for my use upon the termination of my membership or if it is requested for any other reasons. If this equipment or supplies are not returned I promise to pay the replacement value invoiced by the GRVAC. *

All members must be certified by the State of New Jersey as an EMT. Certification can be granted through an act of reciprocity or through and an accredited NJ EMT training facility such as Bergen County EMS Training Center EMT Program. To attend the Bergen County EMS Training Center for the EMT Training Program, the student: Must be 16 years of age at the time of registration for the EMT training class. Must be able to perform at the physical and mental requirements stipulated in the Functional Position Description for the Emergency Medical Technician. Be in good physical condition and be able to lift. Must be able to hear, read, write, communicate, and interpret instructions in the English language.(All text materials are written at the 10th grade level). Must have access to a computer. Must authorize a FERPA (Family Educational Rights and Privacy Act) form that enables communications to take place between the GRVAC and the training facility to determine the student’s progress and any issues that will require further action/s. Must participate in 10 hours clinical observation at a local hospital. Please be advised, for hospital observation time, the student will be required to provide proof of the following documentation: Criminal history check – Initiated by the Bergen County Training Center. Health Insurance - Personal Workman’s Compensation – Provided by the Borough of Glen Rock, NJ Physical examination – Provided by the GRVAC Physician. Mantoux Test. Disease immunity vaccinations or declinations for: Hepatitis B, Flu, MMR, TDAP and Varicella. Please Initial *

When the GRVAC receives this application we will review it, and if you qualify, we will schedule a meeting to further discuss the possibility of becoming a member. This document will need to be signed in person at the time of our meeting. If you are a minor, a parent or guardian will have to attend the meeting with you. *

Type Name *

Signature *

Date *

Parent Consent Form for Applicants who are Minors. If the applicant is younger than 18 years, a parent or guardian must accompany the applicant to a meeting with members of the GRVAC and authorize this Membership Application. I / We hereby grant permission for our son / daughter to participate in the Glen Rock Volunteer Ambulance Corps. Permission includes but is not limited to all training, participation in all duties, functions and activities required by their membership classification. *

Print Parent Name *

Signature *

Date *

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