BUTLER COUNTY EMST RESERVE CORPS APPLICATION

Welcome to the reserve applicant selection process of Butler County Emergency Medical Services (BCEMS) and the Butler County Emergency Medical Services Team (EMST)!   We applaud your decision to apply to serve our citizens as a valued member of our reserve corps!

GENERAL INFORMATION
Your FIRST Name: *
Your Middle Initial:
Your LAST Name: *
Are you currently, or have you ever, been affiliated with any Butler County EMS volunteer organization? * NO YES
Which EMST Department are you currently employed/affiliated with?
Your Email Address: *
Primary Contact Phone #: *
Mailing Address (address/city/state/zip): *
Have you applied with Butler County EMS or the Butler County EMST Reserve Corps before? * YES NO
Have you ever been convicted of a felony? * YES NO
If yes, explain
Does you current driving record contain any moving violations? * YES NO
If yes, explain:
Have you ever been convicted of a crime against a person (ie assault, battery, threat, etc.)? * YES NO
If yes, explain:
CERTIFICATION/LICENSE INFORMATION
KS Drivers License Number *
KS Drivers License Exp Date *
Do you currently hold a valid attendant certification from the Kansas Board of EMS? * YES NO
If yes, what is your current level of certification? FR/EMR EMT EMT-I/AEMT PARAMEDIC
If you are Kansas certified, what is your Kansas Certification Number?
What YEAR does your current certification expire?
Are you also currently certified by the National Registry of EMTs? * YES NO
If yes, what is your National Registry Certification Number?
Please list here any other medical certifications or licenses you currently hold (ie-RN, RT, MT, CNA):
Have you ever had disciplinary action taken against, or revocation taken of, your certification by the Kansas Board of EMS, the National Registry of EMTs, or any other state's EMS certification or regulatory EMS authority?	*	YES NO
If yes, please explain:
Have you ever had disciplinary action taken against, or revocation of, any other currently or once held medical certification/licesne by a state or national regulatory authority?	*	YES NO
If yes, please explain:
OTHER INFORMATION
Please mark any/all of the certifications below that you currently hold: CPR CPR-I ACLS PALS/PEPP BTLS PHTLS NRP AMLS ATLS CEVO-II-A CEVO-III-A EVOC KS TO1 KS TO2 KS I/C HazMat Awareness HazMat Operations ICS 700 ICS 100 IS 200 IS 300 IS 400
ATTACHMENTS
If possible, please attach a copy of your current KS EMS Attendant Certification Card
If possible, please attach a copy of your Kansas Driver's License here
If you have any other useful comments, include them here
MISCELLANEOUS
Who do you know with Butler County EMS/Reserves that we may contact?	*
What actual experience have you had running EMS calls?	*
Have you read the Reserve Program Document?	*	Yes No
Are you willing and able to commit the time necessary to achieve Second Technician status in 6 months?	*	Yes No
Please carefully review all of the information above for accuracy BEFORE pressing the "Submit" button. ALSO PLEASE NOTE: By submitting this form you understand and agree that Butler County EMS reserves the right to conduct background investigations regarding your driving record, your criminal record, and/or your EMS certification record.