1. Name
2. Address Line 1
3. Address Line 2
4. City
5. State
6. Zip Code
7. Phone Number
8. Mobile Number & Carrier
9. Email Address
10. How did you hear about the Ambulance Service
11. Social Security Number
12. Are you a US citizen
13. Are you over the age of 18
14. Do you have a record of founded child or dependent adult abuse?
15. Have you ever been convicted of a felony?

• Required Full timeVolunteerDriverEMTAEMTParamedic
• Available Start Date

1. Most Current Employer
2. Job title
3. Dates Employed
4. Work Phone
5. Starting Pay Rate
6. Ending Pay Rate
7. Address
8. City
9. State
10. Zip

1. Previous Employer
2. Job title
3. Dates Employed
4. Work Phone
5. Starting Pay Rate
6. Ending Pay Rate
7. Address
8. City
9. State
10. Zip

I certify that my answers are true and complete to the best of my knowledge. By signing this volunteer application, I am attesting that I have never been excluded or precluded from participation in Medicare, Medicaid, or any other Federal or State Healthcare program or other wise been debarred or prohibited from contracting with the Federal or Stated government programs. Should I be considered for employment at Louisa County Ambulance Service, I understand that a criminal, abuse and Medicare records investigation will be conducted before an offer of employment is made. I further understand that my employment is at-will and can be terminated at any time, with or without cause or notice. I also understand that personnel policies, programs and procedures may out of necessity change from time to time, such at-will status is not subject to change. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

1. Name:
2. Date:

Given the nature of our work, it is imperative that we maintain the confidence of patient information that we receive in the course of our work. Louisa County Ambulance Service prohibits the release of any patient information to anyone outside the organization unless required for the purposes of treatment, payment, or health care operations and discussions of Protected Health Information (PHI) within the organization should be limited. Acceptable uses of PHI within the organization include, but are not limited to, exchange of patient information needed for the treatment of the patient, billing, and other essential health care operations, peer review, internal audits and quality assurance activities. I understand that Louisa County Ambulance provides services to patients that are private, confidential and that I am a crucial step in respecting the privacy rights of all Louisa County Ambulance Service’s patients. I understand that it is necessary, in the rendering of Louisa County Ambulance services, that patients provide personal information and that such information may exist in a variety of forms such as electronic, oral, written or photographic, and that all such information is strictly confidential and protected by federal and state laws. I agree that I will comply with all confidentiality policies and procedures set in place by Louisa County Ambulance Service during my entire employment or association with Louisa County Ambulance Service. If I, at any time, knowingly or inadvertently breach the patient confidentiality policies and procedures, I agree to notify a supervisor immediately. In addition, I understand that a breach of patient confidentiality may result in suspension or termination of my employment or association with Louisa County Ambulance Service. Upon termination of my employment or association for any reason, or at any time upon request, I agree to return any and all patient confidential information in my possession. This is not a contract for continued employment. I have read and understand all privacy policies and procedures that have been provided to me by Louisa County Ambulance. I agree to abide by all policies or be subject to disciplinary action, which may include verbal or written warning, suspension, or termination of employment or of any membership or association with Louisa County Ambulance. This is not a contract of employment and does not alter the nature of the existing relationship between Louisa County Ambulance and me.

1. Name:
2. Date: