EHAA Membership Application

Member Login

Become an EMT

Apply to join the East Haddam Volunteer Ambulance Association! You may fill out an online application below.

To download a form that can be printed and mailed, click here. Mail the completed form to:
East Haddam Ambulance Association
440 Town Street
East Haddam, CT 06423

Basic Information

Last Name:	First Name:	Middle Initial:
Address:	City:	State:	Zip:
How long at current address:	Daytime Phone:	Evening Phone:
Date of Birth:	Sex: MaleFemale
Email Address:

Certification

Are you currently certified as an EMT/MRT in State of Connecticut? YesNo

Certification number:

Expiration date:

Do you hold any medical training licenses or certifications?YesNo

Describe and list issuing state and expiration dates:

Drivers License Information

Drivers License Number: State: Type:
Have you ever had your license revoked or suspended? YesNo
	List date, state in which revoked/suspended, and details of incident:

Other Information

Have you ever been convicted of a crime? YesNo
	List date(s), state(s), where convicted, and details of incident(s) (DO NOT list parking tickets):

Do you have any physical defects/limitations which would restrict your ability to function as an EMT (lifting, bending, strenuous activity, etc.)? YesNo
	Please describe:

Do you have ambulance training or other medical training? YesNo
	Please describe:

Do you speak any foreign language? YesNo Which?

Reference Information and Emergency Contacts

Please list two references (Name, address, telephone number, relationship):


List your last two employers (Name, address, telephone number, period employed, position, supervisor's name:


In the event of an emergency, who can we contact?
	Name: Relationship:
	Phone Number: Address:

Acknowledgement

Disclosure of information requested in this application is voluntary. However, I understand that failure to provide ALL information requested, or falsification of any information, could jeopardize my approval for membership. I certify that all information and statements I have provided in this application are true and accurate to the best of my knowledge. I authorize the East Haddam Ambulance Association, if deemed appropriate, to contact those references I have listed. Further, I understand that the East Haddam Ambulance Association will request the Resident State Troopers office conduct a criminal records check to confirm the information that I have provided in this application. I understand that this application will become a permanent part of my training and membership records maintained by the East Haddam Ambulance Association. *Disclosure of any information contained on this application will not be made without my specific approval.* If approved for membership, I agree to abide by all rules, regulations, standard operating procedures, and by-laws as set forth by the East Haddam Ambulance Association and state and federal statutes.