membership application


Part I: Pre-Interview Application

Name: ________________________ Email: ____________________________ Phone: (___) ___-____ Graduation Month/Year: ________________ Major: _________________________ Do you have a US Driver’s License? Yes No List any previous volunteer or employment experience: _______________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ Circle highest NYS certification: None CFR EMT-B EMT-I EMT-CC EMT-P CPR Certified? Yes No List any non-NYS EMS certifications: ____________________________________________________ Describe any prior experience with EMS: ________________________________________________ _______________________________________________________________________________________________ What questions do you have about Harpur’s Ferry? ____________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ How many times have you applied to Harpur’s Ferry before? _________________________ What is your greatest strength? ___________ Greatest Weakness? _________________

Part II: Personal Statement

In 250 words or less, why are you interested in EMS? What unique personal attribute do you believe will help you succeed in emergency medicine?

Part III: Photo Identification

Please attach a photo of yourself to the Pre-Interview Application and Personal Statement. *Note: In order to sign up for an interview, you must have all three (3) parts completed and attached. This application packet will be handed in at GIM prior to interview scheduling.