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Full Name *
Physical Address *
City *
State *
2 (Max. 2 Characters)
Zipcode *
Is your mailing address the same or different?
Same
Different
Mailing Address
City
Zipcode
State
Driver's License Number
DL State:
Application Date
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Preferred Contact:
Cell Phone
Home Phone
Cell Phone:
Home Phone:
Is it O.K. to contact you at work?
Yes
No
Work Phone:

References:

Reference #1
Phone Number:
Relationship
Reference #2
Phone Number:
Relationship
Reference #3
Phone Number:
Relationship
Have you been convicted of a traffic violation within the last 5 years?
Yes
No
If yes, please explain:
Have you been convicted of a crime in the past 10 years?
Yes
No
If yes, please explain:
Are you currently charged with a misdemeanor or felony?
Yes
No
If yes, please explain:
Certifications:
American Heart Association CPR
American Red Cross CPR
NYS Emergency Medical Responder
NYS EMT - Basic
NYS EMT - Advanced
NYS AEMT - Critical Care
NYS AEMT - Paramedic
National Registered EMT/AEMT
AHA CPR Instructor
EVOC/CEVO
AHA Expiration Date:
ARC Expiration Date:
NYS Emergency Medical Responder |  Number
NYS Emergency Medical Responder |  Expiration Date
NYS EMT - Basic | Number
NYS EMT - Basic | Expiration Date
NYS EMT - Advanced | Number
NYS EMT - Advanced | Expiration Date
NYS AEMT - Critical Care | Number
NYS AEMT - Critical Care | Expiration Date
NYS AEMT - Paramedic | Number
NYS AEMT - Paramedic | Expiration Date
National Registered EMT/AEMT | Number
National Registered EMT/AEMT | Expiration Date
AHA CPR Instructor | Number
AHA CPR Instructor | Expiration Date
EVOC/CEVO | Expiration Date
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Shift Preferences:

Please indicate the scheduling preferences you have for each day of the week:

Work day preferences:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Shift Hour Preferences:
Please indicate which operation level you are seeking:
Auxillary
Junior Program
Driver
EMT/AEMT
Paramedic

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What is your highest level of education?
GED
High School
Some College
College
Current Employment:
Employed
Unemployed
Self-Employed
Retired
Student
Current Employer
Current School
Expected Graduation
Are you an American Citizen?
Yes
No

Are you applying for a volunteer position?
Yes
No
Have you been a member in the past?
Yes
No
If so, please list dates here:
How did you hear about the Lewis County Search and Rescue?
Why would you like to join Lewis County Search and Rescue?
Have you worked or currently work for another EMS provider?
Yes
No
If so, where and when?
What relevant experience do you have that would help you serve this agency? 

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Membership Agreement and Confidentiality Statement:

I understand that if accepted for membership in Lewis County Search and Rescue, Inc., I will complete the required training as soon as it is available. I also understand that the details of services performed by LCSR are to be held in confidence and I will not release any information unless directed by the manager or his/her designee. I further understand that any violation of the bylaws or standard operating guidelines, or failure to maintain training; unless exempted by the Board of Directors, may result in suspension or termination from LCSR.

Initials

Furthermore, I declare that I have received information pertaining to patient confidentiality. I understand that disclosure of confidential information without proper authorization is a violation of policy, patient’s rights, and federal and state regulations. Such violation will subject me to disciplinary action including possible termination of membership. I understand that violation of the New York State AIDS/HIV information confidentiality law may result in criminal penalties under Article 27-F of the New York State Public Health Law and PHL 800.15. I recognize that I must not disclose confidential information without proper authorization nor should I access confidential information without professional need to know. 

Furthermore, I do understand that Lewis County Search and Rescue reserves the ability to require the following testing and/or checks for  pre-employment, post-accident, and reasonable suspicion: fit for duty testing, reasonable suspicion testing, background checks, driving record check, and reference checks. I understand that my employment may be contingent upon successfully passing all required testing for the agency. 

Signing my name below acknowledges that I agree to all that has been stated above.

I have read the confidentiality statement and promise to comply with its provisions.

Initials
Signature:
Clear
Date Signed
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Location
7782 W State Street
Lowville, New York 13367
Office Hours
  • Billing:
    M-F 8am-4pm
  • Crew Quarters:
    24 hours

Lewis County Search and Rescue is a not-for-profit organization. LCSR does not receive tax dollars, county, state or federal funding to support operational expenses. The service we provide is funded entirely by third party insurance billing and your generous donations. 

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