Thousand Islands EMS
Participation Survey

Please mail to "Ambulance Survey, PO Box 99, Depauville NY 13632"
To print, right click on the form and select "PRINT".

Thank you for your interest in joining Thousand Islands EMS, which will provide Emergency Medical Services to the towns of Clayton and Orleans. We current anticipate having some paid staff, but the rest of the service will be provided by volunteers. The following information will help us in our planning for the new squad.


Address ____________________________________________________________

City, State, Zip ______________________________________________________

Telephone______________________ Email ______________________________

Have you been, or are you now, a member of an EMS service? _________

If yes, which squad?__________________________________________________

We’ll need a variety of skills. In order to help us with planning for the new service, we’ll need to know what level of certification you now hold, used to hold, or would like to train for:

Current Expired Future

q q q None

q q q Driver

q q q First Aid

q q q CPR

q q q Certified First Responder/CFR-D

q q q Basic EMT/EMT-D

q q q Advanced EMT- Intermediate (Level II)

q q q Advanced EMT - Critical Care (Level III)

q q q Paramedic (Level 4)

In addition, we’ll need to know what times of day and days of the week you would like to be available to respond.

Time........Sun,,,,Mon,,,,Tues,,Wed ,,Thurs,,,Fri,,,,,Sat

Days q.....q.....q.....q.....q.....q.....q

Eves q.....q.....q.....q.....q.....q.....q

Nites q.....q.....q.....q.....q.....q.....q

You may have a special skill or profession which would benefit the squad. Care to tell us what it is? ___________________________________

Any other thoughts you’d care to share?