New Member Application (Volunteer) - Hope Valley Ambulance Squad Inc.

Thank you for your interest in applying to Hope Valley Ambulance. This application is for volunteer opportunities with our organization and is not an employment application. Our new member coordinator will reach out to you as soon as possible to discuss your application and next steps.

After applying, you will be directed to our new member session page to schedule an upcoming date for a meeting with our new member coordinator.

Indicates Required Field

Membership Type Required

Demographics and Contact

First Name Required

Last Name

Date of Birth Required

Home Address Required

Email Address

Primary Phone Number Required

Is primary phone a cell phone? If so, can we text with application status updates? Required

Secondary Phone Number (optional)

Prior Applications

Have you ever applied to HVAS in the past? Required

Relevant Licensure, Certification, and Experience

Do you have an EMS license in Rhode Island? Required

If you marked YES above, please provide your RIDOH license number

If you marked YES above, please provide your RIDOH license expiration date

If you marked YES above, please provide where you were trained (program that resulted in your license)

Please mark any certifications you currently hold Required

Note: Members must also hold certifications required by licensure level. Non-licensed members must, at a minimum, hold CPR certification.

None Basic Life Support (BLS) Advanced Cardiovascular Life Support (ACLS) Pedicatric Advanced Life Support (PALS) CPR Certification First Aid Certification

Please describe any relevant experience, training, or certifications. Required

Background and Record

Drivers License Number Required

Driver's License State Required

How many accidents in the last 3 years? Required

Note: Hope Valley Ambulance reserves the right to request or obtain a driving record as a condition of membership acceptance.

How many moving violations within the last 3 years? Required

Note: Hope Valley Ambulance reserves the right to request or obtain a driving record as a condition of membership acceptance.

Have you ever been changed with any criminal violation? If yes, please explain. Required

Current Employer Required

Previous Employer(s) Required

Emergency Contact

Emergency Notification Contact (Name) Required

Emergency Notification Contact (Phone Number) Required

Emergency Notification Contact (Relationship) Required

Agreements

Please agree to statement 1 by typing your full name Required

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.

Please agree to statement 2 by typing your full name Required

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.

Please agree to the following instructions Required

Part of the application process requires the following documents from you: driver's license, BCI (RI state criminal background check), immunization record, Basic Life Support (BLS CPR) certification, and any medical licenses (EMT, Paramedic, etc.) These documents are not required for initial submission of 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

ONLY if applying as a Junior Member: agree to the following statement

This application was submitted with the permission of and under the supervision of a parent or legal guardian. Junior program particiaption requires signed parental consent, which will be obtained later in the applciation process.

After submitting your application, you will be directed to our new member session scheduling page.