Member - Chatham Emergency Squad

Your Information

Experience

References

Signature

First Name *

Last Name *

Do you have a nickname or preferred to be called by something else?

Yes

Nickname

Mobile / Cell Number *

Email Address *

Home Phone Number

Address *

How Long Have you Lived at this Adddress? *

Previous Address

Birthday

Are You 18 Years or Older? *

Yes

We are sorry, but all of our members must be at least aged 18 with a vaid driver's license. We encourage you to apply to be a member after turning 18. If you have any questions, kindly reach out to our Membership VP.

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Do You Have a Driver's License? *

Yes

State Issued

Driver's License Number

We're very sorry, but all active members are required to have a driver's license as we exepct all EMTs to drive the ambulance. Please reach out to us if you have any questions.

Email Our Membership VP

Thank you.

Are you Married (or have a partner)? *

Yes

Spouse / Partner's Name

Hobbies, Interests

Languages Spoken

Please provide us with three references not related to you. Please provide at least one reference from your place of work or former place of work, as appropriate.

Reference 1

Name *

Phone *

Email *

Reference 2

Name *

Phone *

Email *

Reference 3

Name *

Phone *

Email *

How Did You Hear About the Squad? *

Please Provide More Details

Anything Else We Should Know?

Emergency Contact Name *

Relationship *

Phone Number *

Email *

Applicant's Declaration

I authorize the Chatham Emergency Squad to conduct driving-record checks and background checks before being accepted to membership and at any time while I am a member. I understand that the findings of those checks will be factors in determining acceptance into and continuance of membership.

I have reviewed the CES Medical Form and attest to all qualifications as stated. I am aware that certain physical and psychological demands will be made of me and I attest to my ability to fulfill such demands. My physician will complete and sign the CES Medical Form confirming my physical and psychological fitness to function as a New Jersey EMT. In addition to the qualifications listed on the CES Medical Form, I am aware that I must be able to always:

Use good judgment and remain calm in high-stress situations including illness and injuries that could include heavy bleeding, cardiopulmonary resuscitation (CPR), and other medical emergencies,
Effectively communicate in the English language with co-workers, patients, police, members of the public, and medical personnel,
Function well in environmentally extreme conditions including heat, cold, darkness, and confined physical spaces.

I understand that prior to starting my membership, I will have to complete and pass a CES-provided BLS CPR class. If I am accepted into membership, I agree to comply with all Bylaws and Standing Rules of the Chatham Emergency Squad. *

Yes

I certify that all answers provided are true to the best of my knowledge. I also understand that any deliberate misstatement on this application is sufficient cause for rejection or dismissal. *

Yes

Please Sign Below to Complete Your Application Using Your Mouse or Finger (The "submit button will appear after doing so): *

Clear

Unfortunately, we can not accept this application as you are either under the age of 18 or you do not have a valid driver's license. Kindly contact our Membership VP if you have any questions.

Membership Form