Rehoboth Ambulance Committee, Inc
PO Box 156
Rehoboth, MA 02769
Phone: 508-252-2318
Fax: 508-463-0842

Membership Application

Thank you for your interest in the Rehoboth Ambulance Committee. To be considered for membership, please complete the application below. You will be contacted by a member of the Committee to schedule an interview.

If you are applying as an active EMT or Paramedic, please understand that the Rehoboth Ambulance has the following requirements:

  • You must work a minimum of 24 hours per month to remain active
  • You are expected to submit availability for at least one night per month. You may or may not be schedueld for that night based on overall availability submissions from the rest of the staff
  • You are expected to work your night shifts more often then trying to trade or give them away
  • If you are unable to meet these requirements, but still wish to apply, please discuss your concerns during the interview

Denotes required field
Please note there are multiple tabs in the application.


  • 1Demographics
  • 2Emergency Contacts
  • 3Licenses
  • 4Education
  • 5References
  • 6CORI Release
  • 7Submit Application



Same as Residential



At least one emergency contact is required

Emergency Contact 1



Emergency Contact 2



Are you currently a Massachusetts Licensed EMS Provider?

Educational Background - All Applications please complete

Education Name of School Course of Study Degree/Diploma Date of Graduation
High School
EMS Training (highest level)
Other Education

Please provide three references not related to you

Name Phone Number Years Known How do you know them?

Please provide the following additional information to allow us to request your CORI. Providing this information online via this application is optional, and will expedite the scheduling of your interview.
If you choose NOT to provide the information here, you will be required to complete a separate CORI authorization prior to your interview.

Do you wish to provide the necessary CORI information?

By submitting this application, I affirm that all information contained within is true and accurate. I also affirm my understanding of the following staffing requirements:

  • You must work a minimum of 24 hours per month to remain active
  • You are expected to submit availability for at least one night per month. You may or may not be schedueld for that night based on overall availability submissions from the rest of the staff
  • You are expected to work your night shifts more often then trying to trade or give them away
  • If you are unable to meet these requirements, but still wish to apply, please discuss your concerns during the interview