Volunteer Member Application
Please use this form to apply to Exchange Ambulance of the Islips! This form will be forwarded to our membership committee and they will be in contact with you!
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Name *
Phone Number *
E-Mail Address *
Street Address
City *
State
Type Of Membership Desired *
Are you AHA BLS Provider certified? *
Do you hold a NYS EMT certification? *
Have you ever belonged to another Fire or EMS agency in the past or currently? *
If yes, where?
Do you have any previous EMS or medical experience? *
If yes, where?
Occupation
What is your availability? Please keep in mind we require each of our members to commit to 6 hours of duty each week after the initial training period. We are a 24/7 emergency service and we have crews scheduled around the clock 365 days a year. (Select All That Apply)
12am to 6am
6am to 12pm
12pm to 6pm
6pm to 12am
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Are you available either Sunday or Wednesday night for training for the first 6 months of membership? *
Why do you wish to join Exchange Ambulance of the Islips? *
How did you hear about Exchange Ambulance of the Islips?
Referred by (Optional):
Riding Members Only: Are you looking to become an EMT and/or drive the ambulance? Please keep in mind that we require all our riding members to complete an EMT certification course (if not already done so) or become a cleared ambulance driver within the first 2 years of membership.
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This form was created inside of Exchange Ambulance of the Islips.