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VOLUNTEER

Volunteer with The Westhampton War Memorial Ambulance Association

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If you would like to become a Westhampton War Memorial Ambulance Association volunteer, please complete, and submit our volunteer application.

APPLICATION: Westhampton War Memorial Ambulance Association
Are you 18 years of age or older?
Is additional information about a change in your name or your use of an assumed name or nickname necessary to enable a check on your eligibility for membership?
Are you currently employed?
May we contact your organization as a reference?
Do you have a valid New York State Drivers License?
Please indicate your availability to participate in normally required ambulance activities (meetings, drills and emergency calls.) Please check appropriate time periods.
Do you have any previous emergency services experience? (Include only fire, rescue, police, and emergency medical service agencies).
Have you ever been a member of the United States Armed Forces?
If the answer is “Yes”, did you receive a dishonorable discharge?
Have you ever been convicted or pled guilty to a felony, misdemeanor, insurance fraud, arson, or a reduction of one of these offenses?

REFERENCES

Please list three personal references, other than members of this organization, who have known you for at least 3 years.

Regulations require that you pass a physical examination that includes a drug screen before becoming an ambulance volunteer. The department’s physician will provide you with a free medical examination. Will you be willing to undergo a medical examination?
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PRIVACY NOTIFICATION

 

Section 94 of the Public Officers Law (Personal Privacy Protection Law) requires that you be notified of the following facts when information that will be maintained in the record system is collected from you.

 

The authority to request and confirm personal information about you is found in Article 6 of the Executive Law.

 

The information obtained will:

 

Be used to determine your qualifications for the position for which you are  applying;

 

Be maintained in your personnel file (if you become a member) or in our resume file for six months (if you are not an ambulance member).

 

Failure to provide the information or authorization will result in your application not being considered for membership.

 

The information will be maintained by the secretary of the Westhampton War Memorial Ambulance Association.

 

 

 

APPLICANT’S AUTHORIZATION FOR RELEASE OF INFORMATION

 

In order to confirm the information I supplied on my application for membership with WWMAA, I authorize all licensing agencies, educational institutions, law enforcement agencies, present and former organizations, and the military services to disclose their relevant records about me to WWMAA whether the information is of public, private or confidential nature; and I release them from any liability and responsibility from doing so.

 

This authorization, in original copy form, shall be valid for this and any future information, reports, or updates that may be requested.

 

I understand that this form will accompany requests for official documents and confirmations of my credentials.

DRIVING RECORD ABSTRACT RELEASE

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In connection with my membership or employment with the Westhampton War Memorial Ambulance, I understand that a driver’s license abstract may be requested and obtained. These reports may include information related to my previous driving record including court actions, citations, license suspensions, and revocations.

 

I AUTHORIZE ANY PARTY OR AGENCY CONTACTED TO FURNISH THE ABOVE-MENTIONED INFORMATION.

 

I have the right to obtain information as to the name, address, and phone number of any agency providing such information and further may request of that agency, upon proper identification, the nature and substance of all information in its files on me at the time of my request, including all sources of information as well as the recipient(s) of any reports on me which the agency has furnished within the two (2) year period preceding my request. This authorization shall remain on file and serve as ongoing authorization for the organization to procure Motor Vehicle Reports at any time during my active membership in the organization.

Thanks for submitting!

Please upload a copy of your driver's license.

WITHIN THE FREEDOM OF INFORMATION LAW, ALL INFORMATION CONTAINED/OR OBTAINED HEREIN WILL REMAIN CONFIDENTIAL AND WILL BE USED ONLY FOR INTERNAL MEMBERSHIP PROCESSING

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In witness whereof, this application has been subscribed by the undersigned applicant who affirms that the statements made herein are true under the penalties of perjury.

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