Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
Instructions for Completing RPVAC Membership
Application
♦ Please Print.
♦ List two references on the application and have the two letters of
reference forms completed by the same people listed on the
application.*
o References cannot be members of the Ridgefield Park Volunteer
Ambulance Corps and cannot be relatives.
♦ You must go to the Ridgefield Park Police Department to be
fingerprinted and return page 12 to RPVAC.*
o 234 Main Street, please call ahead and confirm that a detective
is available. (201)641-6400.
o An appointment is REQUIRED with a Detective.
♦ You must obtain/ pick up your driver’s license abstract from
GJEM Insurance Company and return it to RPVAC.*
o 363 Cedar Lane ~ Teaneck, NJ 07666
o Phone- (201) 641-3800, Fax- (201) 641-9236
♦ Complete these four required online courses and hand in certificates.
o ICS 100, 200,700, 800
o http://training.fema.gov/EMIWeb/IS/is100b.asp
o http://training.fema.gov/EMIWeb/IS/is200b.asp
o http://training.fema.gov/EMIWeb/IS/is700b.asp
o http://training.fema.gov/EMIWeb/IS/is800b.asp
♦ Hand in any previous Training Certs (if any) including but not limited to:
o Epi-pen, CEVO, Defensive Driving, ICS, BBP
*You will not be voted on until these tasks are completed
Page 1 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
Membership Application
Date: ____________
Desired Membership Class:
□ Probationary Member (Must attend EMT school within one year)
□ Associate (Must be EMT)
Driver
Full Name: ____________________________________________________________
Address:
____________________________________________________________
____________________________________________________________
Home Phone: _____________________
Cell Phone:________________________ (Provider)_________________________
E-Mail Address: _______________________________________________________
Date of Birth: ______________________ Social Security #_______________
Drivers License # __________________________ State: ________
Exp.________
Employer: ______________________ Phone Number: _____________________
Address: ______________________________________________________________
EMERGENCY CONTACT INFORMATION
Last Name: ______________________First Name:_________________________
Address: _________________________________City: _________________
State: ____ Zip Code: _____
Phone #1. (_____) ____________________ 2. (_____)____________________
Last Name: ______________________First Name:_________________________
Address: _______________________________City: _________________
State: ____ Zip Code: _____
Phone #1. (_____) ____________________ 2. (_____)_____________________
Page 2 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
Why do you wish to join RPVAC?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Do you have any physical limitations or illnesses that would
preclude you from performing the duties of EMS?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Previous EMS Experience:
Have you ever been a member of RPVAC?  Yes  No If so
when?____________
Have you ever been a member of a Commercial or Volunteer
Ambulance before?  Yes  No
If yes, where and what dates? _________________________________
____________________________________
Are you still a member?  Yes  No
Reason for leaving? _______________________________________
Are you a member of any other Emergency Services (Fire, Rescue,
Police, Paramedic)?  Yes  No
If yes, what and where? ____________________________________
Page 3 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
List any RPVAC members whom you know:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Previous Training:
Training
Location
Expiration Date
 CPR
_________________________
___________________
 EMT
_________________________
___________________
 HAZMAT
_________________________
___________________
 ICS
_________________________
___________________
 Other
_________________________
___________________
_
Please detail any other non-medical training or experience that you feel
may be an asset to RPVAC.
______________________________________________________________________________
Personal References:
RPVAC requires two personal references. Each must complete and return one of
the enclosed Personal Letters of Reference Forms and return it to RPVAC.
References cannot be members of the Ridgefield Park Volunteer Ambulance
Corps and cannot be relatives. Please list the two people you will give the forms
to:
Name: _________________________________________________
Address: ______________________________________
Phone number: __________________________________
Name: _________________________________________________
Address: _________________________________________
Phone number: __________________________________
Page 4 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
Criminal and Driving History:
Have you ever been convicted of any crime in New Jersey or elsewhere?
 YES  NO If yes, please explain: _______________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list any moving violations that you have had in the past 18
months:
______________________________________________________________________________
______________________________________________________________________________
Please list any accidents that you have had in the past 3 years:
______________________________________________________________________________
______________________________________________________________________________
I hereby authorize inquire by the Corps of all statements contained in this
application and release those individuals from any and all liability and
damage resulting from or arising out of such investigations. I understand
that any misrepresentation or omission of facts in this application is
cause for immediate dismissal from the Corps.
I consent to taking a pre-membership physical exam and such future
exams as may be required by the Corps. I agree to comply with all Rules
and Regulations and By-Laws governing the Corps, and further agree to
return any and all equipment and/or clothing loaned to me by the Corps
upon relinquishing my membership in RPVAC.
I HEREBY DECLARE THAT ALL THE ABOVE STATEMENTS ARE TRUE.
Applicant’s Signature
____________________________________________________
Date: ____________________
Page 5 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
Waiver and Consent
To: Any Enforcement Agency
Re: Ridgefield Park Volunteer Ambulance Corps (RPVAC)
I am an applicant at RPVAC. I recognize that I may be called upon to
operate a motor vehicle of/for RPVAC and that I will require a valid
driver’s license in order to do so.
I also recognize that if I am accepted for membership I will be involved in
the answering of emergencies. The attainment of such a position requires
that an applicant be trustworthy and have high integrity, and be
physically fit.
Therefore, I realize it is necessary for the Corps to request a Police check
of my records, both as to the operation of a motor vehicle and as to any
other record I may have with law enforcement agencies in this State, or
any other State, or the Federal Government. I also understand that I
must be fingerprinted by the Ridgefield Park Police.
I, hereby, give permission to the Ridgefield Park Police Department, with
regards to a check on my records and consent that a search of any report
as to any records of law enforcement authorities regarding me be made.
(Signed)__________________________
(Date)__________________
Please Print:
Full Name: ___________________________________
Address:
_____________________________
_____________________________
Date of Birth: _____________________________
Social Security #: _______________________
Drivers License #: _______________________
State: _______________________
Expiration Date: _______________________
Page 6 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
Computer and Internet Usage Contract
The Ridgefield Park Volunteer Ambulance Corps (“Corps”) agrees to allow the member identified below (“Member”) to use the Corps
technology to access the Internet under the following terms and conditions:
1. Conditional Privilege: The member’s use of the corps access to the Internet is a privilege, not a right, and conditioned on the member’s
abiding by this agreement.
2. Acceptable Use:
Transmission or intentional receipt of any inappropriate material or material in violation of law or Corps policy is prohibited. This includes, but is
not limited to: copyrighted material; threatening or obscene material: material protected by trade secrets; the design or detailed information
pertaining to explosive devices: criminal activities or terrorist acts;
sexism or sexual harassment; pornography; gambling; illegal solicitation; racism; inappropriate language; use of product advertisement, or
political lobbying.
It is against Corp policy to disclose personal information, such as home address, phone
numbers, passwords, credit card numbers or social security number; this also applies to others’ personal information or that of the Corp.
3. Penalties for Improper Use: Any misuse of the internet, destruction, modification or abuse of the Corps computers and/or network will revoke
the member’s access to the network. And member will be referred to the disciplinary committee disciplinary committee for review.
“Misuse of the Corps access to the Internet” includes, but is not limited to the following
a. Using the Internet for any activities deemed lewd, obscene, vulgar, or pornographic as defined by prevailing community standards;
b. Using abusive or profane language in private messages on the system; or using the system to harass, insult, or verbally attacks on others;
c. Posting anonymous messages on the system;
d. Using encryption software;
e. Wasteful use of limited resources provided by the Corp including paper;
f. Causing congestion of the network through lengthy downloads of files;
g. Vandalizing data of another user;
h. Obtaining or sending information which could be used to make destructive devices such as guns, weapons, bombs, explosives, or fireworks;
i. Gaining or attempting to gain unauthorized access to resources or files;
j. Identifying oneself with another person’s name or password or using an account or password of another user without proper authorization;
k. Theft or vandalism of data, equipment, or intellectual property;
l. Invading the privacy of individuals;
m. Using the Internet for any illegal activity, including computer hacking and copyright or intellectual property law violations;
n. Introducing a virus to, or otherwise improperly tampering with, the system;
o. Degrading or disrupting equipment or system performance;
p. Creating a web page or associating a web page with Corps without proper authorization;
q. Attempting to gain access or gaining access to members records or files.
r. Providing access to the Corps internet access to unauthorized individuals;
s. Taking part in any activity related to Internet use which creates a clear and present danger of the substantial disruption of the orderly operation
of the Corps.
t. Making unauthorized copies of computer software;
u. Installing software on Corps computers is prohibited.
Wireless Access
Wireless configuration must be done by a member of the computer committee:
The password that is provided will not be shared with member requesting access.
I understand that e-mail and files saved on the network are not private
I understand that any violation of these expectations will result in revocation of e-mail/Internet access rights. Any violation will make me liable
for appropriate disciplinary actions.
Member Name (Print): _____________________________________________________
Member Signature: ________________________________________________________
Date: ___________________________
I understand that once on the internet, access to information is not regulated. I give my
permission for my son/daughter to obtain access to the Internet.
Parent’s Name (Print): _____________________________________________________
Parent’s Signature: ________________________________________________________
Date: __________________________
Page 7 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
For Corps Use Only:
Committee Members:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Date Called: ____________________
Date Interviewed: _____________
RECOMMENDATION
 Accepted
 Rejected (attach reason)
 Copy of Driver’s License
 DMV Abstract Obtained
 Fingerprints
 Two Letters of Reference
*Detach following pages and give to the applicant*
Page 8 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
MEMO
PLACE ORIGINAL DRIVERS LICENSE
HERE AND COLOR FAX TO NUMBER
BELOW
Date:__________________
To: GJEM Insurance
201.641.9236 – fax
From: RPVAC
Re: License Abstract Authorization
GJEM Insurance is authorized to run the drivers license abstract for
___________________________________ - Applicant at Ridgefield Park Volunteer Ambulance
Corps
Applicant Contact Number:____________________________________
Thank YOU
Authorizing Signature
Name and Rank
GJEM
CC: Matt McArow
363 Cedar Lane
Teaneck, NJ 07666
201.641.3800 – phone
201.641.9236 – fax
*Note to member* bring form with you to GJEM
Page 9 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
Welcome to the Ridgefield Park Volunteer Ambulance Corps
We are glad that you have chosen to become apart of our family. There are many benefits
to being a member of The Ridgefield Park Volunteer Ambulance Corps. The Ridgefield Park
Volunteer Ambulance Corps has a call volume of about 1,200 calls per year. A wide array of
emergencies allow EMT’s to gain great experience and also allow them to hone BLS skills in a
supportive environment. We work very closely with the Ridgefield park police department, fire
department, and heavy rescue squad along with various Bergen county EMS agencies including
paramedics. We provide all members with workers compensation-style insurance coverage in
case of duty related illness or injury.
We would like to familiarize you with some of the basic requirements of the Corps.
Members are required to ride a minimum of 12 hours a week. You will be assigned a duty night
based on open shifts and your availability. We suggest that you ride on a few different nights to
get a feel for different crews and crew chiefs before choosing a specific night. We operate 24/7
365. Members are expected to arrive on time for their shifts, which means arriving 15 minutes
prior to the start of shift to check and properly stock the ambulances prior to going in service.
Night shifts begin at 5:45 PM and day sifts begin at 5:45 AM. Both the Corps and The village of
Ridgefield Park are counting on you to put an ambulance in service on time. If you are going to
be late (after 5:45PM on nights or 5:45AM on days) you must contact your crew chief
immediately. If at any time your shift commitment becomes burdensome, please speak with your
crew chief and/or the scheduling officer to readjust your schedule, as we do not want to loose
valued members. We are flexible, but keep in mind that we have to staff an ambulance every
night of the week. This is a volunteer organization, but that does not mean we are not a
professional organization. It is our members’ responsibility to be here for their committed shifts,
act with maturity, and to treat others with respect.
You will be issued a uniform and will be expected to look professional when riding or
participating in corps functions. We hold ourselves to high standards and take pride in our
organization. Dressing the part is a major factor. The corps supplies all members with all
uniform attire however it is every member’s responsibility to acquire a pair of black ankle high
work boots and a black belt. When wearing your uniform remember you are representing the
Corps and the village of Ridgefield Park.
Members are allowed to park when on duty in the spots marked ambulance corps when
not on duty leave these spots for the crew on call for the night. Lockers are available to keep
personal items such as toiletries, spare clothes/uniforms, linens etc. The corps is equipped with 2
computers for shared use along with wireless Internet for members to connect their own laptops
to. Meetings are held on the first Tuesday of each month at 7pm. All members are encouraged to
attend. If members are unable to attend we ask that you notify the president prior to the meeting.
Page 10 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
Medical Release Form
______________________________________ has applied to join the Ridgefield Park
Volunteer Ambulance Corps. Service with our Corps may involve stressful situations, lifting and
carrying patients, stretchers, and equipment, exposure to biological and non-biological hazards,
driving of an emergency vehicle, and prolonged periods without rest, meals, and/or access to
medication. Our EMT’s must be able to display calm under pressure, critical and time-sensitive
problem solving, ability to communicate effectively, and physical endurance.
Examples of medical conditions that may put him/her and others in danger might include
epilepsy, significant cardiac history, infectious disease, severe anxiety or other psychiatric
conditions, physical impairment, bleeding disorder, neurological disorder, uncontrolled
hypertension, uncontrolled diabetes, and hearing impairment.
We ask that you supply medical information concerning the above named applicant to
assist us in determining if he/she would be able to successfully perform all of the duties of a
Corps member.
Do you feel that this applicant can physically and mentally perform as a member with the
Ridgefield Park Volunteer Ambulance Corps?
_____YES
_____NO
_____CONDITIONALLY
Please Explain.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Physician
Signature_____________________________________________________Date____________
Physician Name:
Telephone Number:
Address:
State of License:
License Number:
Physician stamp below:
Page 11 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
Ridgefield Park Police Department
Detective Division
234 Main Street
Ridgefield Park, NJ 07660
(201) 641 – 6400
The Ridgefield Park Volunteer Ambulance Corps is requesting confirmation that the individual
listed below has successfully had fingerprint retrieval and documentation by the Ridgefield Park
Police.
Date: ____________________
Name: __________________________________________________ DOB: ________________
Police Department Use Only:
Officer Name:______________________________
Badge Number:_____________________________
Officer’s Signature: _________________________________
**RPVAC applicant: please return this form to your interview committee**
Page 12 of 13
Volunteers since 1952
Ridgefield Park Volunteer Ambulance Corps
48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770
www.ridgefieldpark.org
Ridgefield Park Police Department
Detective Division
234 Main Street
Ridgefield Park, NJ 07660
(201) 641 – 6400
Date: ____________________
I, ___________________________________, authorize the Ridgefield Park Police Department
to release any pertinent information regarding my legal history to the Ridgefield Park Volunteer
Ambulance Corps which is to be obtained via fingerprint retrieval and documentation. I
acknowledge that this may affect my membership application process with the Ridgefield Park
Volunteer Ambulance Corps.
Name: __________________________________________________ DOB: ________________
Signature:_________________________________________________
Thank you,
Ridgefield Park Ambulance Corps
**RPPD: please keep this form for your record**
Page 13 of 13
Volunteers since 1952