Membership Application

Applicant Information

Date*

Position Requested*

Full Name*

Address*

City*

State*

Zip*

Cross Streets (Between)*

And*

Work Phone

Home Phone

Cellular Phone*

Cellular Carrier*

Fax

E-mail*

Driver's License #*

State*

Plate #*

Date of Birth*

Marital Status*

No. Yrs. Married

No. of Children

Employment & Education

Employer

Position

Employer Address

Phone

Yeshiva Ketana

H.S.

Beis Medrash

College

Shul (Shabbos)*

Rabbi*

Medical Experience

Other Experience / Abilities

Projected Availability

If accepted as a member, what is your projected availability in each of the following weekday time periods?

9 AM - 5 PM: Location*

5 PM - 11 PM: Location*

11 PM - 9 AM: Location*

Character and/or Professional Medical References

Name*

Title*

Phone*

Name*

Title*

Phone*

Name*

Title*

Phone*

Certification

I certify that all information provided on my application for membership in Hatzoloh of Flatbush is factual. I understand that as part of the screening process, the Membership Committee will make inquiries regarding my drivers license as well as seeking character references from individuals who are acquaintances of mine. If accepted into Hatzoloh I agree to the terms and conditions of the attached Agreement. I also understand that it is the policy of the Membership Committee of the Flatbush Division of Hatzoloh not to discuss outside of the Committee the reasons leading to a decision of acceptance or denial of any membership application, to any individual, including the applicant, under any circumstances whatsoever. Please include a copy of your Driver's License, Vehicle Registration, Insurance, and EMT Card with this application.

Driver's LicenseClick to upload

Vehicle RegistrationClick to upload

InsuranceClick to upload

EMT CardClick to upload

Signature (type full name)*

Date*

Agreement

Hatzoloh is a volunteer organization which provides medical assistance in emergency situations. All members must adhere to the rules, regulations, and policies of the Flatbush Division of Hatzoloh. Any newly admitted member is considered to be in a probationary status for his first six months of service. I agree to abide by all rules and regulations of Flatbush Hatzoloh both written and oral. I have read this agreement and fully agree with the terms of membership in the Flatbush Division of Hatzoloh.

Signature (type full name)*

Print Name*

Date*

New Member Background Check Authorization

I declare that all information given in this application is true and correct. I authorize Flatbush Hatzoloh to verify and obtain my Driving records and Criminal records, and to utilize this information for Hatzoloh purposes only.

First Name (Legal Name)*

Middle Initial

Last Name*

Date of Birth*

Current Address*

City*

State*

Zip*

Phone Number*

Cell Number*

Driver License Number*

State*

Applicant Signature (type full name)*

Date*