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Thank you for applying as a volunteer.  Please fill the fields below to submit your application.  A member of the personnel committee will contact you within 72 hours.

 

Date:*
Name:*
Address:*
E-Mail:*
Primary Phone:*
-
Secondary Phone:
-
Gender:*
Are you under 18 years old?*
Date of Birth:*
Are you currently employed?*
Have you been employed?*
Name of Most Recent Employer:*
Address of Most Recent Employer:*
Highest Education Completed:*
Have you volunteered at any other EMS or Fire organizations?*
Name of EMS or Fire Organization:*
Reason for Leaving:*
Why do you wish to join our volunteer ambulance corps?*
Are you involved in any groups or organizations?*
Are you fluent in any languages other than English?*
Are you REQUIRED to perform community service?*
Have you ever been convicted of a misdemeanor or felony crime?*
Has this or any other ambulance organization ever denied your membership?*
Have you ever been disciplined by any agency or organization while serving as a health care provider?*
Has your driver's license ever been suspended or revoked?*
Select any applicable certifications or licenses you hold:
Certification/License #*
Reference #1:*
Reference #1 Phone:*
-
Relationship to Applicant #1:*
Reference #2*
Reference #2 Phone:*
-
Relationship to Applicant #2:*
Member Referral?
I affirm that the above application contains no misstatements or omissions and is completely true and correct. If my application is accepted, I agree to abide by all the rules and regulations of the Little Neck - Douglaston Community Ambulance Corps ("LNDCAC") at all times. I further authorize LNDCAC to verify the information I have provided in this application. False statements made here on this application may result in my suspension and/or revocation of membership.

By accepting membership to LNDCAC, I agree to serve during designated hours and make myself available at such times. In addition, I am expected to offer my time whenever possible when called upon to relieve a fellow member. I may be called upon in an emergency even though it may not be my duty time.

I understand that my membership application will be reviewed by the Operations Committee who will determine if approved for membership, and I understand that my application is conditional on the following requirements: (a) If applying for ambulance duties, I have been examined by a medical physician who has determined me to be fit for those duties and (b) having completed a 6-month probationary period. During that time, corps officer and the training and operations committee wil have monitored and evaluated my performance.

By digitally signing my name below, I hereby accept and agree to all the terms of this application.

Signature:*
Signature Date:*

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Many thanks to Dan Hurley for the original creation of this site.