Application for Membership

Community Emergency Corps, INC.

78 Thompson Street

Ballston Spa, NY 12020

Application for Membership

Name_________________________________________________

Address_______________________________________________

_______________________ NY___________Zip Code_____________

Previous Address (if less than 3 years)_________________________________________

_________________________________________

Home Phone (____)_______________ Business Phone (____)_________________

Cell Phone (____)_______________ Pager (____)_________________

(optional) (optional)

Occupation______________________ Place of Business_____________________

Do you possess a valid NYS Operator’s License? ______

License number_________________________________ Expiration Date____/____/____

(You must be 18 years of age to be a member, 21 years of age to drive)

Have you been convicted of any driving infractions within the last 5 years?______

If so, please list details_____________________________________________________

Are you willing to drive an ambulance?______

List all current First Aid Certifications and expiration dates.________________________
____________________________________________________________________

____________________________________________________________________

Hours of availability-

Sun____-____ Mon____-____ Tue____-____ Wed____-____

Thu____-____ Fri____-____ Sat____-____

(Currently, By-laws require 36 hours during week, 12 hours weekend duty per month)

Health status- Excellent____ Good____ Fair____ Poor____

List 3 references, including your employer. No family members, please.

Name__________________ Name__________________ Name__________________

Addr.__________________ Addr.__________________ Addr.__________________

__________________ __________________ __________________

Phone__________________ Phone__________________ Phone__________________

Do you currently, or have you in the past, belong to any other volunteer organizations? If so, please list._________________________________________________________________________________

Have you ever been convicted of a crime (other than traffic infractions listed above)? If so, please list._________________________________________________________________________________

I hereby respectfully submit my application for active membership in the Community Emergency Corps and in doing so, I agree to abide fully with the rules and regulations of the organization, it’s Constitution and By-Laws, and to take an active part in it’s activities. _________ (initial)

I further agree to take an active part in drills, instructions, courses, and any other activity in which the Community Emergency Corps may participate or sponsor. _________ (initial)

I also agree that, if admitted to the membership, within 9 months of admission, I will enroll in an approved course to begin the training required of ambulance attendants by state and/or federal law. I will keep my training current as required by the Constitution and By-Laws of the Corps. __________ (initial)

I understand that applicants are screened as to their character and ability to serve as active members prior to consideration as a member. Therefore, I hereby consent that the Community Emergency Corps may conduct such investigations as may be reasonable to establish my qualifications for membership as set forth by the Constitution and By-Laws of the Corps. I agree to serve a six month probationary period during which time the investigation may continue. At the end of the six month probationary period, the Board of Directors will approve or disapprove permanent membership.

I have read and understand all of the above and, to the best of my knowledge, all of my information is true.

Signature________________________________

Date_____/_____/_____