New EMT Application – Harpswell Neck Fire and Rescue

What a Licensed EMS Clinician Does

Duties

- Be familiar with the use of rescue equipment and supplies within license level and with their location in the ambulance.
- Provide patient care at the direction of a paramedic from Mid Coast Hospital or the senior Harpswell Neck Rescue EMS provider on scene.
- While at Mid Coast Hospital, replace the supplies and medications used on the call. Ensure decontamination of the ambulance and equipment after a call.
- Submit a Maine EMS electronic report within 24 hours of completing a call.

Requirements

- Present evidence of immunizations/immunity to five childhood diseases:
  - Mumps, measles, German measles, chicken pox and pertussis (whooping cough)
- Present evidence of an annual flu shot or sign a declination form.
- A valid driver’s license.
- A valid Maine EMS license.
- Initial and annual driving record check and an initial criminal background check.
- In-house driver training and Maine Emergency Vehicle Operator’s Certification (EVOC).
- Bureau of Labor Standards/OSHA initial and annual training. (We provide the training.)

Schedule and Training

- Work 12-hour shifts weekly
- In-house training – 2 hours monthly
- You will receive a pager and radio for monitoring your shift at home or at the station.

Application Form

Legal Name

First

Middle

Last

Today's Date

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Physical Address (if different)

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone

Email Address

Best Time(s) to Contact You

Place of Employment

Occupation

Work Phone

Emergency Contact

First

Last

their Work Place

Relation

Emergency Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Phone

Why do you want to volunteer with Harpswell Neck Fire and Rescue?

What role(s) are you interested in?

Please indicate any EMS or fire training you have completed, with date of completion.

Please indicate any other training that may be of value to the fire department, with date of completion.

If a member of HNFR recommended that you join, please provide their name.

Please provide three references

Reference 1

First

Last

Reference 1 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 1 Phone

Reference 2

First

Last

Reference 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 2 Phone

Reference 3

First

Last

Reference 3 Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference 3 Phone

Entering my name below attests to the accuracy of the information provided and releases the fire department to obtain a driving record history, contact references and complete a criminal background check.

Name