Volunteer

Name *

First

Last

Address *

Date of Birth *

Home Phone *

Work Phone

Cell Phone

Email *

CT DMV Operators Lic. # *

Exp. Date *

Have you had any infractions in the last 5 years? If yes, please explain. *

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone #1 *

Emergency Contact Phone #2 *

Current Employer (Name) *

Current Employer (Address) *

Current Employer (Phone) *

Current Employer (Position) *

Current Employer (Supervisor) *

Marital Status:

Single
Married
Divorced
Widowed

High School Attended:

Years Completed:

1
2
3
4

College Attended:

Years Completed:

1
2
3
4

CT DPH Certification (Lic. # and Exp. Date):

CT DPH Certification (City/State/Year Work was Completed):

CT DPH Certification (Instructor Name):

List any other training you have received and are currently certified in that would be of value to the KAA:

Previous EMS experience (list agencies, time of service and reason for leaving):

Have you ever had any disciplinary actions / charges brought against you as an EMS provider? If Yes, please explain.

Do you have any disabilities, ailments or impairments that might require modifications to allow you to perform in EMS service with KAA? If yes, please explain.

Have you ever been convicted of a felony involving moral turpitude? If yes, please explain.

Please provide three (3) references we can contact: (Name/Phone/Relationship for each)

In a brief paragraph state your reasons for wanting to join the KAA, what you expect to gain from membership, and what the KAA can gain from you.

Applicant's Affidavit: I authorize investigation of any and all statements made in this application. I understand that misrepresentation or omission of facts requested may be cause for dismissal. Further, I understand and agree that my acceptance is dependent upon the successful completion of all required training. I will conduct myself in a professiona manner consistent with my training at all times in dealing with my superiors, my peers, other agencies with which we have contact, and of course patients. *

I have read and agree to the above affidavit