Community Responder Apply On-Line

Please be aware that due to the nature of the schemes and the need to coordinate training programmes, we will only be recruiting in specific areas across the region at any particular time. After you have completed the registration form, you should receive a written answer within five days as to whether we are recruiting in your area.

If we are recruiting in your area, we will ask you to attend an interview and provide proof of identification in order to apply for a Criminal Records Bureau (Enhanced) check. If we are not recruiting in your area, we will ask you to re-apply in 12 months time.

If you feel you fit the bill and would like to be considered for selection when vacancies become availabe, please complete the form below.

Fields marked with a * are compulsory.

Title
First Name*
Last Name*
Email*
Address*
Post Code*
Telephone (Daytime)*
Telephone (Evening)*
Date of Birth*
Occupation
Employer's Address
Employer's Post Code
Your employer will NOT be contacted.
Please supply details of 2 referees who would be prepared to provide a character reference. This MUST NOT be a member of your own family, but can be your employer or a family friend.
Reference 1
Referee Name*
Address*
Post Code*
Telephone*
Reference 2
Referee Name*
Address*
Post Code*
Telephone*
Why do you want to become a Community Responder?*
At West Midlands Ambulance Service we strive to ensure that we provide the best possible service to all members of the community that we serve. It would be helpful if you could answer the following questions:
Gender:	Do not wish to disclose Male Female
Ethnic Origin:	Do not wish to disclose Asian or Asian British: Bangladeshi Asian or Asian British: Indian Asian or Asian British: Other Asian Asian or Asian British: Pakistani Black or Black British: Black African Black or Black British: Black Caribbean Black or Black British: Other Black Chinese or Other Ethnic Group: Chinese Chinese or Other Ethnic Group: Other Ethnic Group Mixed: Other Mixed Mixed: White and Asian Mixed: White and Black African Mixed: White and Black Caribbean White: British White: Irish White: Other White
Which term best describes your sexuality:	Do not wish to disclose Bisexual Gay Heterosexual Lesbian
Please indicate your religion or belief:	Do not wish to disclose Atheism Buddhism Christianity Hinduism Islam Jainism Sikhism Other
Do you consider yourself to have a disability/impairment?	Do not wish to disclose Yes No
If Yes to above question, please indicate below all that apply to you.
Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark Other.	Learning Disability/Difficulty Long-Standing Illness Mental Health Problem Physical Impairment Sensory Impairment Other
Please be assured that all information will remain anonymous.

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