Membership Application - Croton On Hudson Volunteer EMS

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Membership Application

Croton Emergency Medical Services

44 Wayne Street
Croton on Hudson, NY 10520
Phone - 914-862-1600
Fax - 914-862-1601

Indicates Required Field


Personal Information

Name:
Date of Birth:
Address:
Telephone Number:
Email Address:
Member Sponsoring This Application (if applicable):
Are you 18 years of age or older:		No Yes
If no, are you age 17 and a NYS EMT, or enrolled in a course to become one:		No Yes
Are you a citizen of the United States:		No Yes
Have you ever worked in EMS before:		No Yes
If so, where:
If so, for how long:
Reason for Leaving:
Please list any EMS certiﬁcations, and/or relevant training courses and dates taken (and expiration, if applicable):

Please List Three References (Name, Email Address, Cell Phone Number)

Reference #1:
Reference #2:
Reference #3:
Electronic Signature of applicant:
Date:
If accepted as a member of Croton Emergency Medical Services, Inc., I will abide by the Constitution of the United States; laws, rules and regulations of the New York State Department of Health, Westchester County WREMSCO, and of the Croton EMS By-Laws and Standard Operating Guidelines, and will faithfully fulﬁll all of the requirements of membership. I understand that intentional falsiﬁcation of this document, violating the Constitution and/or By-Laws, may result in immediate dismissal from Croton EMS.

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www.FirehouseSolutions.com	Croton On Hudson Volunteer EMS P.O. Box 358 Croton on Hudson, NY 10520	Emergency Dial 911 Non-Emergency: 914-862-1600 Station Fax: 914-862-1601 E-mail: info@crotonemsinc.org