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| Demographics and Contact |
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| First Name:
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| Last Name:
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| Date of Birth:
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| Home Address:
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| Primary Phone Number:
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| Is primary phone a cell phone? If so, can we text with application status updates?:
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| Secondary Phone Number (optional):
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| Prior Applications |
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| Have you ever applied to HVAS in the past?:
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| Relevant Licensure, Certification, and Experience |
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| Do you have an EMS license in Rhode Island?:
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| If you marked YES above, please provide your RIDOH license number:
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| If you marked YES above, please provide your RIDOH license expiration date:
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| If you marked YES above, please provide where you were trained (program that resulted in your license):
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Please mark any certifications you currently hold:
Note: Members must also hold certifications required by licensure level. Non-licensed members must, at a minimum, hold CPR certification.
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None
Basic Life Support (BLS)
Advanced Cardiovascular Life Support (ACLS)
Pedicatric Advanced Life Support (PALS)
CPR Certification
First Aid Certification
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| Please describe any relevant experience, training, or certifications.:
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| Background and Record |
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| Drivers License Number:
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| Driver's License State:
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How many accidents in the last 3 years?:
Note: Hope Valley Ambulance reserves the right to request or obtain a driving record as a condition of membership acceptance.
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How many moving violations within the last 3 years?:
Note: Hope Valley Ambulance reserves the right to request or obtain a driving record as a condition of membership acceptance.
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| Have you ever been changed with any criminal violation? If yes, please explain.:
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| Current Employer:
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| Previous Employer(s):
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| Emergency Contact |
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| Emergency Notification Contact (Name):
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| Emergency Notification Contact (Phone Number) :
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| Emergency Notification Contact (Relationship):
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| Agreements |
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Please agree to statement 1 by typing your full name:
To the best of my knowledge, I attest that I am in good physical health. I am able to perform the duties which are required, which are not limited to heavy lifting, pulling, stretching, bending, being out in inclement weather or near hazardous conditions, and being able to perform under stressful situations. I understand that Hope Valley Ambulance Squad, Inc. may request that I obtain a medical clearance from a licensed physician to perform duties involved with Hope Valley Ambulance Squad, Inc.
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Please agree to statement 2 by typing your full name:
I understand and authorize Hope Valley Ambulance Squad, Inc. to conduct a criminal and personal background check, and that any misconduct found may result in denial of acceptance into the organization. I further understand that any misrepresentations, omissions, false information, or other misconduct discovered after acceptance may result in dismissal/termination from the organization. I attest that the information provided is true, accurate & complete to the best of my knowledge.
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Please agree to the following instructions:
To expedite the application process, it is highly recommended to obtain a background check ("BCI") from the RI Attorney General's office and email a copy to: Brathbyn@hvamb.org. Including a copy of your driver's license and a copy of any medical licenses or certifications is also recommended.
These documents are not required to submit your application, but are required for future application approval and eventual membership acceptance.
Background check info: https://riag.ri.gov/about-our-office/divisions-and-units/bureau-criminal-identification-bci
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