Membership – Chevra Hatzolah of Middlesex County

First Name (Legal)*

Last Name*

Date of Birth*

Sex*

Marital Status*

Applicant's cell phone*

Applicant's e-mail address*

Applicant's home address*

Applicant's emergency name*

Applicant's emergency contact cell*

Applicant's emergency contact relationship*

Desired Position*

What days are you usually available for calls?*

Sunday - Please list or clarify your availability*

Monday - Please list or clarify your availability*

Tuesday - Please list or clarify your availability*

Wednesday - Please list or clarify your availability*

Thursday - Please list or clarify your availability*

Friday - Please list or clarify your availability*

Shabbos - Please list or clarify your availability*

Do you have a drivers license?*

Please upload a photo of the front and back*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 2.

Has your drivers license ever been revoked, or have your driving privileges ever been suspended?*

Please explain*

Shuls attended*

Please fill in the name and location of the shul(s) that you attend*

Rov's Name*

Rov's cell*

Are you currently working?*

Applicant's Occupation*

Applicant's Work Address*

Please explain why you are not working*

Have you ever provided patient care in an EMS system?*

Please detail*

Do you have any medical certifications?*

Please upload a photo of each (front & back)*

Drop files here or

Accepted file types: jpg, png, gif, pdf, doc, docx, Max. file size: 256 MB.

Are you a US citizen?*

Explain why not*

Have you ever been convicted of a crime?*

Please explain*

By checking I Agree and clicking SUBMIT, you are electronically affirming that all information contained in this application has been entered truthfully, to the best of your knowledge and ability.

You acknowledge that Chevra Hatzolah of Middlesex County (and any of its duly appointed representatives) has the right to conduct a full background check on any applicant, regardless of the position being applied for, and that additional information, such as a social security number, may be requested for this purpose.

The information that you have provided will be verified. It is understood that the purpose of any background check is solely to maintain the safety of our patients, the organization, and the community at large. This information will be kept confidential. Additionally, Chevra Hatzolah of Middlesex County reserves the right to investigate how you are perceived within the community due to the membership being a reflection of the organization. Furthermore, we reserve the right to consult your parent(s), spouse, shul rov, or anyone else that we feel the need to, in order to determine if you are a fit for the organization.

Submission of an application, or being contacted at any time during the investigation process, does not, in any way, imply or guarantee acceptance.

I Agree*

Yes

Name

This field is for validation purposes and should be left unchanged.