Galway Emergency Medical Services - Membership Application
* FIRST NAME
:
SOCIAL SEC #
-
* LAST NAME
* HOME PHONE #
* ADDRESS
* DATE OF BIRTH
: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
/
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918
E-MAIL
* EMERGENCY CONTACT
* EMERGENCY PHONE #
EMPLOYER
WORK PHONE #
WORK EXT.
DRIVERS LICENSE #
STATE OF D.L.
: State CT NY OH
< EXPIRATION DATE
Year 2006 2007 2008 2009 2010 2011 2012 2013
* ARE YOU WILLING TO DRIVE AN ABULANCE?
: Select Yes No
SHIRT SIZE
: Size S M L XL XXL
* TOUR DESIRED
: Select 6 AM - 6 PM 6 PM - 6 AM Other (specify)
COAT SIZE
OTHER (if selected)
* TYPE OF MEMBERSHIP
: Select Active Seasonal
* LIST ALL TRAFFIC VIOLATIONS FOR PAST 3 YEARS
Please enter information or N/A if none.
* LIST ALL TRAFFIC ACCIDENTS PAST 3 YEARS
* LIST ANY CIVIL OR FELONY CONVICTIONS
* LIST ANY PHYSICAL LIMITATIONS
Please enter any Certification Training Below
TRAINING
DATE OF EXPIRATION
LOCATION
ID #
C.P.R.
Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
COMMUNITY FIRST AID
E.M.T.
1-ST RESPONDER
OTHER MEDICAL TRAINING
LIST OF ORGANIZATIONS YOU BELONG TO
I ACKNOWLEDGE THAT I WILL BE ON PROBATION UP TO (6) MONTHS AND ALL THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE, AGREE TO ABIDE TO THE CONSTITUTION / BY-LAWS AND S.O.P.'S OF THE GALWAY EMERGENCY MEDICAL SERVICES, AND AUTHORIZE GALWAY EMERGENCY MEDICAL SERVICES TO OBTAIN INFROMATION REGUARDING MY BACKGROUND. I Accept the above Terms and Conditions of this Application
Please print the completed form and mail it to:
Galway EMS
2175 Galway Road
Galway, NY. 12074
* Required Field REVISED 01-20-05
