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 o 234 Main Street, please call ahead and confirm that a detective is available. (201)641-6400. ♦ You must obtain your driver’s license abstract from GJEM Insurance Company and return it to RPVAC o 25 Mt. Vernon Street ~ Ridgefield Park, NJ 07660 o (201) 641-3800 ♦ Complete these four required online courses and hand in certs 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 Epi-pen, CEVO, Defensive Driving, ICS, BBP Page 1 of 12 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: □ Associate Driver □ Probationary Member(Must attend EMT school within one year) 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 12 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 12 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 12 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 12 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 12 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 Page 7 of 12 Volunteers since 1952 Ridgefield Park Volunteer Ambulance Corps 48 Main Street ~ Ridgefield Park ~ New Jersey ~ 07660 ~ 201-641-4770 www.ridgefieldpark.org MEMO Date:__________________ To: GJEM Insurance From: RPVAC Re: License Abstract Authorization GJEM Insurance is authorized to run the drivers license abstract for ___________________________________ - Applicant at Ridgefield Park Volunteer Ambulance Corps Thank YOU Authorizing Signature Name and Rank GJEM 363 Cedar Lane Teaneck, NJ 07666 201.641.3800 – phone 201.641.9236 – fax Page 8 of 12 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 9 of 12 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 al 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 10 of 12 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 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:_____________________________ Signature Whom Administering Fingerprints: _________________________________ **RPVAC member: please return this form to your interview committee** Page 11 of 12 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 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 Page 12 of 12 Volunteers since 1952