Membership Application – The Cambridge Valley Rescue Squad, Inc. (CVRS)

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Name *

First

Last

Address *

"Best" Phone *

Email *

Date of Birth

Driver's License

Have you ever been convicted of a felony or misdemeanor? *

No
Yes - If yes, please explain in the Comment Section below

A previous felony or misdemeanor conviction may preclude certification as an Emergency Medical Technician - NYS DOH BEMS Policy Statement 09-05.

Comment or Message

Have you been convicted of any traffic violations in the past 2 years? *

No
Yes - If yes, please explain in the Comment Section below

Comment or Message

Do you have any health problems or physical disabilities that may limit your participation? *

No
Yes - If yes, please explain in the Comment Section below

Comment or Message

List any previous or current involvement with other emergency service organizations (include department and dates):

List any medical or related training:

Please list 3 personal or professional references: *

Include name, address, and "best" phone number. Do not list relatives. Only include one CVRS member if applicable.

CVRS MISSION STATEMENT - The mission of CVRS is to be educated, forward thinking, and innovative Emergency Medical Service Providers who are dedicated to providing professional, compassionate, and patient focused pre-hospital health care to the communities we serve. *

Please initial that you have read the statement above.

CVRS VISION - The CVRS vision is to create a healthy and safe community by continually providing high-quality emergency medical care and innovative programs and services that improve the health of our communities. *

Please initial that you have read the statement above.

CORE VALUES - Compassion. CVRS members pride themselves on providing a high level of compassion to their patients, patient’s family and friends, other EMS providers, those in health care, and the community. Volunteerism. CVRS has a long standing history of a strong volunteer base. Volunteerism is critical to the mission and vision of the organization, to the point that volunteers will be supported in all possible means to achieve that mission and vision. Respect. CVRS demands that its members treat the organization, each other, its patients, the community, and the institution of EMS with respect. Service. CVRS made a commitment to the greater Cambridge community to provide high quality, timely emergency medical care. Service to the community includes developing and implementing programs that promote improved health, safety, and well-being of the community. Training. CVRS members must maintain a high level of subject knowledge to meet the mission and vision of the organization. Training that is relevant to improving patient care and organizational management will be a primary focus in agency decision making. Education. CVRS’ membership, including leadership, will have basic educational understanding in areas such as interpersonal communication, organizational behaviors, fiduciary responsibility, mental well-being, and personnel management to fulfill the mission and vision of the organization. Advocacy. CVRS members will advocate for its patients safety and well-being through interactions with other healthcare providers. Furthermore, CVRS will be an advocate for the organization and for the institution of Emergency Medical Services. *

Please initial that you have read the statement above.

CONDUCT - Please read the following passages from CVRS’ By Laws and initial that you have read, understand and agree abide by their provisions: It is the responsibility of every member to be familiar with and abide by the current By-Laws and Standard Operating Procedures of the organization. CONFIDENTIALITY - The confidentiality of patient information is both a legal and ethical obligation of emergency medical service providers. HIPPA (Health Information Portability Protection Act) is designed to simplify the administration of the health insurance industry and by setting national standards for transfer of protected health information, confidentiality of protected information, and the management of health care financing. *

Please initial that you have read the statement above.

PROFESSIONALISM & JUDGMENT - A Professional is defined as one who has the professional status, methods, character and standards. When reporting for duty, one should be of a frame of mind conductive to the job to be performed. While representing CVRS, it is incumbent upon you, the member, to meet everyone in a professional and dignified manner that will reflect well upon both yourself and CVRS. All members will at all times use good judgment within the parameters of their training or generally accepted social, ethical and legal guidelines. The determination of Professional behavior and good judgment will be made by the Crew Chief on duty or any CVRS officer at any time. When wearing the CVRS insignia off duty, members are expected to continue to act in a professional manner. By wearing the insignia, you are acting within the scope of a member of CVRS. *

Please initial that you have read the statement above.

CVRS MINIMUM REQUIREMENTS AND EXPECTATIONS - The following are the minimum requirements and expectations to be considered an “active” member: • All approved applicants shall be placed on a six (6) month probationary period effective the date of acceptance. During the probationary period the member shall complete the CVRS Onboard program, complete minimum competency training courses, and attend a membership meeting. • Required to be on duty a minimum of twenty-four (24) hours per month, scheduled to work within the member’s schedule. • Must complete a minimum of twelve (12) hours of training per year (more may be necessary to meet the requirements of NYS EMS certification). • Drivers must complete a driver training curriculum and be authorized by the Assistant Chief of Operations. • Required to complete and maintain certifications in CPR, National Incident Management System, and any other required administrative or operational training. *

Please initial that you have read the statement above.

Affirmation - In signing this application for membership, I agree to abide by the By-Laws and Standard Operating Procedures of the organization. I agree to return all equipment issued to me by CVRS upon termination of service. I further state that all information in this application is true to the best of my ability. *

Please sign and date the affirmation statement above.

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