EMT Academy Application

• Full Name [required]:
• E-Mail Address [required]:
• Phone # [required]:
• Street Address:
• City:
• County:
• State:
• Zip:

• Are you legally allowed to work in the United States?
• Yes
  No
• Have you ever applied for employment with us?
• Yes
  No
• Have you ever worked for Lancaster EMS?
• Yes
  No
• If 'Yes', when were you employed by us? (MM/YYYY format, please)
• -
• If 'Yes', please tell us why you left
• Are you 18 years of age or older?
• Yes
  No
• Have you ever been convicted of a felony or criminal misdemeanor?
• Yes
  No
• If 'Yes', please explain

• What is the highest level of education you have completed?
• High school diploma / GED Associate degree (2yr) Bachelor's degree (4yr) Master's degree or higher
• Do you hold a valid PA Drivers License?
• Yes
  No
• If not already enrolled/vetted by PA CAREERLINKS are you willing to be?
• Yes
  No
• Are you willing to submit the following background checks?:
  • PA State Police EPATCH Criminal History
  • FBI Criminal History
  • PA Childline Criminal History
  • PA Individual Driver Record History
• Yes
  No
• Do you have access to reliable transportation?
• Yes
  No
• Do you have reliable access to the internet?
• Yes
  No
• Do you have access to desktop or laptop PC that has access to the internet? A smartphone alone does not meet this criteria.
• Yes
  No
• Are you willing to work various shifts, extend your work hours as needed to ensure coverage, and in general, work in a outside environment?
• Yes
  No

The EMT Academy Canidate must also demonstrate competency in handling emergencies utilizing basic life support equipment in accordance with the objectives in the National Highway Traffic Safety Administration EMS Education Standards for EMT and other objectives identified by the Department, including the following:

• Will you be able to verbally communicate in person, via telephone, telecommunications, and other electronic devices using the English language?
• Yes
  No
• Will you be able to hear and interpret spoken information from co-workers, patients, physicians and dispatchers and sounds common to the emergency scene?
• Yes
  No
• Will you be able to lift, carry, and balance a minimum of 125 pounds equally distributed (250 pounds with assistance), a height of 33 inches, a distance of 10 feet?
• Yes
  No
• Will you be able to read and comprehend written materials under stressful condition?
• Yes
  No
• Will you be able to verbally interview patient, family members, bystanders, and hear and interprets their responses?
• Yes
  No
• Will you be able to document physically in writing all relevant information in prescribed format?
• Yes
  No
• Will you be able to demonstrate manual dexterity and fine motor skills, with ability to perform all tasks related to quality patient care?
• Yes
  No
• Will you be able to bend, stoop, crawl, and walk on uneven surfaces?
• Yes
  No
• Will you be able to meet minimum vision requirements to operate a motor vehicle within the state?
• Yes
  No
• Will you be able to function in varied environmental conditions such as lightend or darkened work areas, extreme heat, cold, and moisture?
• Yes
  No

• Please list at least three professional references not related to you. Be sure to provide complete addresses and phone numbers.
• Reference One: Name
• Reference One: Occupation/Title
• Reference One: Address
• Reference One: Contact Info (phone, e-mail or both)
• Reference One: Years Known
• Reference Two: Name
• Reference Two: Occupation/Title
• Reference Two: Address
• Reference Two: Contact Info (phone, e-mail or both)
• Reference Two: Years Known
• Reference Three: Name
• Reference Three: Occupation/Title
• Reference Three: Address
• Reference Three: Contact Info (phone, e-mail or both)
• Reference Three: Years Known

• Have you ever been discharged, asked to resign, or resigned to avoid discharge from any position?
• Yes
  No
• How did you hear about employment with Lancaster EMS?
• ... Lancaster EMS Recruitment Video Lancaster EMS Employee Lancaster EMS Website Employment Fair/Expo Facebook Indeed Other
• May we contact your current employer?
• Yes   No   Not Currently Employed

I certify that all the information provided in this employment application is true and complete to the best of my knowledge. I understand that any false information or omission may disqualify me from further consideration for employment or may result in my dismissal if discovered at a later date.

I authorize the investigation of any or all statements contained in this application and authorize any person, school, current employer (unless otherwise indicated below), past employer and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I release such persons and organizations from any legal liability in making such statements.

I understand that if an offer of employment is extended, it will be contingent upon me successfully passing a pre-placement physical examination, including a urine drug screen, to determine my ability to perform the essential functions of the position for which I have applied. I consent to the release of any or all medical information as may be deemed necessary to make this judgment.

I further understand that any offer of employment will also be contingent upon the results of a Pennsylvania State Police Criminal Background Check, a Child Abuse History Clearance and a review of my Motor Vehicle Record (separate forms will be utilized to obtain consent for these requests).

I understand that neither this application, any segment of the hiring process nor any subsequent offer of employment will constitute a contract of employment nor guarantee employment for any definite period of time. If hired, I understand that Lancaster EMS maintains a policy for "Employment at Will" and that continued employment is based upon the mutual consent of employer and employee. Likewise, said employment may be terminated at any time by either the employer or the employee with or without notice.

• My signature attests that I have read, understand, and agree to each of the above statements and conditions. [required]
• Date (MM/DD/YYYY) [required]
• I have read, understand, and agree to each of the above statements and conditions. [required]
• Yes