membership application
General Information
Thank you for your interest in becoming a member of Pittsford Volunteer Ambulance, to help us continue the tradition of care to the town of Pittsford and surrounding communities as we have for over 30 years. The following application will start the membership process.

The first step in becoming an active member is to be trained as a dispatcher. To be cleared as a Dispatcher, applicants must have completed Community First Aid, AHA CPR for the Healthcare Provider or American Red Cross CPR, Bloodborne Pathogens Awareness, HIPPA Privacy Practices and complete an on-the-job training period with dispatch trainers.

To be cleared as a Second Medic, applicants must be complete a New York State EMT, CFR or ER certification as well as AHA CPR for the Healthcare Provider or American Red Cross, HIPPA Privacy Practices, HAZMAT and Bloodborne Pathogens Awareness.

To be cleared as a First Medic, an applicant must be certified as an NYS EMT-D (or higher), AHA CPR for the Healthcare Provider or American Red Cross, HIPPA Privacy Practices, HAZMAT and Bloodborne Pathogens Awareness.

To be cleared as a Driver, an applicant must be certified in Emergency Response (ER) or higher, as well as AHA CPR for the Healthcare Provider or American Red Cross CPR, HAZMAT, HIPAA Privacy Practices and Bloodborne Pathogens Awareness and be cleared as a Second Medic.

The above certifications are NOT required in order to become a member of PVA. Applicants who do not have the appropriate certifications will receive training and certifications for any position.
All active members including those in training, are required to volunteer a minimum of 12 hours per month. We encourage members to work as much as possible, especially while training; to maintain and learn new skills.
Active members must be at least:
  16 years old to be a Dispatcher (or 15 years old and an Explorer Member)
  14 year old Explorer Members may apply for Active Membership but must be
15 years old before clearing as a Dispatcher.
  18 years old to be a Medic
  21 years old to be a Driver

Additional information including copies of the By-Laws, Rules and Regulations, Dispatcher, Medic, and Driver Manuals will be provided at orientation.

Application Instructions
Complete the membership application form. Indicate if you have completed any Emergency Service certification but are awaiting a card/paperwork. Make sure to read the disclaimer before submitting the form.
If you have any questions, please call our dispatcher at (585) 385.2401 and leave a message for the Membership Chairperson, who will return your call.
The Membership Committee will make the decision regarding your potential membership with Pittsford Volunteer Ambulance. The Membership Chairperson will contact you in approximately 2-3 weeks with the final decision of the committee.

Thank you for choosing Pittsford Volunteer Ambulance. We appreciate your interest in volunteering with us.

Personel Information

Date:

Full Name:

Street Address:

Apt. Number:

City/Town:

State:

Zip Code:

Telephone Number:

Cellular Number:

Pager Number:

Email Address:

Date of Birth:

Drivers License Number:

Drivers License Expiration:

State of Drivers License Issuance:

Emergency Contact Name:

Emergency Contact Phone Number:

Positions Desired:

Dispatcher:

Driver:

Medic:

How did you hear about volunteering at Pittsford Ambulance?

D&C Brighton-Pittsford Post
Television Ad Sign at our base
Other:

Have you ever been a member of any Emergency Service Agency?

Yes No
    Supervisor/Chief:
   

Please list any past or present Emergency Service Certifications held:

Please list any special skills or interests you may have:

Are you currently employed?

Yes No
    Address:
   

Do you have any medical condition that could interfere with the performance of your duties as Dispatcher, Driver, or Medic?

No

* If you answered 'Yes' to the above question, you must have a physical examination and a statement from your physician stating any restrictions or limitations in performing the duties of Dispatcher, Driver, or Medic.

Have you ever been a member of the United States Armed Forces?

No

If Yes, Did you recieve an other than Honorable discharge*?

No

*If you answered 'Yes' to this question, give complete details including service branch and service dates in the 'Additional Information' Section at the end of this form.

Have you ever been convicted or plead guilty to a felony or misdemeanor?

No

*If 'Yes' give complete details in the 'Additional Information' Section at the end of this form.

References

Please list three (3) personal or business references that have known you for at least three (3) years.

Reference 1

Name:

Address:

Telephone Number:

Best time to call:

Reference 2

Name:

Address:

Telephone Number:

Best time to call:

Reference 3

Name:

Address:

Telephone Number:

Best time to call:

Please list the names of any Pittsford Ambulance members that you know:

Additional Information

Disclaimer

Within the Freedom of Information Law, all information contained and/or obtained herein will remain confidential and will be used only for internal membership processing. By submitting this application I hereby state that all questions have been answered truthfully and without omission, and I further acknowledge that by submitting this online application I authorize the officers of Pittsford Ambulance to check any or all of the above statements with the proper Enforcement Agency (s). I also understand that willful falsification or omission from this application will subject it to immediate rejection. It is further understood that Pittsford Volunteer Ambulance does not discriminate membership due to sex, race, religion, creed, national origin, or sexual orientation.