NSW Ambulance Legacy

NSW Ambulance Legacy Membership Form

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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth

Date

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* 4. Address

Address *

Address 2

City/Town *

State *

Post Code *

Country *

Email Address

Phone Number *

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* 5. Preferred Contact Method

Phone

Mail

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* 6. Service Details (Locations during your career)

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* 7. Date commenced employment?

Date

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* 8. Status

Currently Employed

Retired or separated from NSW Ambulance Service or another emergency medical service provider

Volunteer

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* 9. Date you finished your employment?

Date

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* 10. Opt in to NSW Ambulance Legacy public contact list

Members details will remain private unless you opt to be added to a open membership list.
Would you like your contact information to be visible to other members?
This contact list will be for other members only and will not be shared outside of NSW Ambulance Legacy. People violating this privilege will have their membership reviewed.

Yes include me on the list visible to other members

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* 11. Associate Membership
NSW Ambulance Legacy will proudly offer Associate Membership the spouse or partner of a member.

Membership clause 1.3

All associate members must meet one of the following criteria:

(a) Spouse or partner of member in good standing

(b) Spouse or partner of NSW Ambulance employee who died or seriously injured in the course of his or her duties

(c) Spouse or partner of NSW Ambulance Employee who died or faced permanent impairment due to ill health

(d) Other former employees or volunteers of NSW Ambulance approved by the NSW Ambulance Legacy Committee

Associate Membership required?

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* 12. Associate Membership First Name

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* 13. Associate Member Last Name

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* 14. Date of Birth

Date

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* 15. Address

Address

Address 2

City/Town

Post Code

Phone Number

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* 16. DISCLAIMER
By becoming a member of NSW Ambulance Legacy, individuals are required to comply with the CORE values of NSW Ambulance.
Members agree to represent NSW Ambulance and NSW Ambulance Legacy in ways that do not bring NSW Ambulance or NSW Ambulance Legacy into disrepute or that are prejudicial to NSW Ambulance or NSW Ambulance Legacy.
NSW Ambulance Legacy Constitution is available on NSW Ambulance website, http://www.ambulance.nsw.gov.au/about-us/Legacy.html

I agree to the terms outlined above.