Please Note:
RIT Ambulance is a volunteer agency with a minimum GPA requirement of 2.3.

Personal Information
University Id
First Name
Middle Name
Last Name
Email Address
Phone Number
Gender	Male Female
Date of Birth (MM/DD/YYYY)
Local Address
Street Address
Apartment/Suite
City
State
Zip Code
Home Address
Street Address
Apartment/Suite
City
State
Zip Code

RIT Affiliation

I am an RIT StudentI am RIT Faculty or Staff

Current Certifications (Check all that apply)

First AidCPRNYS EMTOther EMT

Previous Medical Experience

You may add any number of past experience entries. You must click "Save Past Experience" to save your entered data.

Name and Location of Organization
Responsibilities
Dates
Hours per Month
Contact

Driving Record

Valid Driver's LicenseYesNo

Additional Personal Data

Positions Interested InDriverMedicDispatcher

Additional Training SoughtEMTA-EMTEVOC/CEVO

Please describe any physical/mental disabilities you feel may affect your participation.

List any actions taken against you by the Rochester Institute of Technology in which formal charges and/or actions were taken against you by Student Affairs or by other campus authorities.

If you have ever been convicted of a crime, please explain.

Personal Statement

In this personal statement, please include any hobbies, talents, or special interests that you have, why you are interested in joining RIT Ambulance, and how you feel you can best serve this organization and the RIT community.

I, the undersigned, certify that the information given on this application is correct and complete. I authorize RIT Ambulance, or any of its agents, to check any and all of the information contained in this application for membership. I understand that if I become a member of RIT Ambulance, and this application is found to be incomplete or inaccurate, appropriate actions may be taken by RIT Ambulance, or any of its agents, as it deems necessary. I further understand that RIT Ambulance is a volunteer organization and I expect no type of pay or compensation for my duties. I further understand that active membership in RIT Ambulance requires a minimum scholastic average of 2.3 on a 4.0 scale.

Type Full Name