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Posted by savac

Contact Information
Name :(required)
College Address :(required)
Home Address :(required)
College Year :
Freshman Sophmore Junior Senior Graduate
Birth Date :(required)
College Phone :
Mobile Phone :(required)
Oswego Email Address(required)
Alternate Email Address
Expected Year Of Graduation :(required)
To Be Notified In Case of Emergency
Name :(required)
Address :(required)
Relationship :(required)
Home Phone :(required)
Work Phone :
Medical Training (NO Experience needed to join)
Standard First Aid Expiration Date :
Advanced First Aid Expiration Date :
CPR Expiration Date :
Water Safety Expiration Date :
Certified First Responder ID :
Certified First Responder Card Expiration Date :
Emergency Medical Techinican Number :
Emergency Medical Technician Card Expiration Date :
Instructor (List Courses) :
Other Training :
Driver’s License Data (If Applicable)
Lisense ID :
Expiration Date :
Convictions :
Previous Emergency Services Experience
Are You a member of an Ambulance or Fire Department ?(required)
If Yes , Where and for how long ?(required)
What Position Would You Like:
Helper Driver Attendant (Must be a New York State Certified EMT)
Medical History: (Strictly Confidential by New York State Law)
Do you have a history of any of the following ?
Psychological Disorders :(required)
Emotional Disorders :(required)
Medical Disorders :(required)
Serious Illness :(required)
Diseases :(required)
Please Describe anything you checked as YES :(required)
Will you agree to have a physical if required during your membership :(required)
Criminal History
Have you been convicted of any felonies or misdemeanors in the past seven (7) year's ?(required)
If YES, please describe the conviction, the date of conviction, and the trial court :(required)
I hereby certify that all information provided on this application is correct and accurate to the best of my knowledge and I am aware that any false statements made on this application, in addition to any blatant violations of the Rules and Regulations governing SAVAC, Student Association activities, the State University of New York College at Oswego, local, county, state, and federal laws while performing duties in the name of the Student Association Volunteer Ambulance Corps of Oswego is prohibited and could result in the suspension or expulsion from the corps as well as legal action. I also understand the privilege of patient confidentiality and understand that releasing any patent information to anyone other than certified authorities is punishable by federal law and could result in suspension or expulsion from the corps and possible judicial action. I also understand that SAVAC is entitled to run a background check on me with any and all agencies it deems necessary.
Date of Application :(required)

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