| This
is just a preliminary application form. Filling it out does
not obligate you to join the rescue squad, this is just
a chance for us to get to know a little more about you.
Everything you submit to us will be kept confidential and
will not be used for any purpose other than reviewing your
eligibility as a prospective member of VSRS. We will contact
you as soon as we review your information. Thanks for your
interest. |
| Full
Name |
|
| Address |
|
| City |
|
| State |
|
| Zip |
|
| S.
S. Number |
|
| Home
Phone |
|
| Work
Phone |
|
| Cell
Phone |
|
| Email |
|
| Occupation |
|
| Age |
|
| Date
of Birth |
|
| What
hours are you available to respond to emergencies? |
|
| Military
Service Branch |
|
| Date
Entered Military |
|
| Date
Discharged from Military |
|
| Driver
License # |
|
| Drivers
License State |
|
| Drivers
License Type |
|
| Drivers
License Restrictions |
|
| Have
you been convicted of a traffic violation in the past 10
years? |
| |
|
| If
yes, list below |
| |
| Education:
Please select highest grade completed |
| High
School |
|
| College |
|
| College
Degree? |
|
| Degree
Type? |
|
| Major? |
|
| Post
Graduate? |
|
| Have
you ever been convicted of a crime? (omit
any conviction before 18th birthday) |
|
| If
yes, list below |
|
| |
| In
case of emergency, name of nearest relative
|
|
| Address |
|
| City |
|
| State |
|
| Relationship |
|
| Phone
Number |
|
| Reference
1 (non-related) |
|
| Name |
|
| Relationship |
|
| Address |
|
| Phone |
|
| City |
|
| State |
|
| Zip |
|
| Reference
2 (non-related) |
|
| Name |
|
| Relationship |
|
| Address |
|
| Phone |
|
| City |
|
| State |
|
| Zip |
|
| List
any medical, rescue or dive skills, date obtained, agency
& location. |
|
|
| Rescue
operations may require the applicant to undergo periods
of very strenuous physical activity therefore, please answer
all questions below. If any answers are yes, please explain
in the box provided. |
| Blood
Type (if known) |
|
| Height |
|
| Weight |
|
| Have
you ever had a serious injury? |
|
| Have
you ever had a hernia or rupture? |
|
| Have
you ever had back trouble of any kind? |
|
| Have
you ever had an allergy or drug reaction? |
|
| Do
you need to wear glasses at any time? |
|
| Have
you ever been advised to have an operation? |
|
| Do
you have any physical limitations which would prevent you
from participating fully in rescue operations? |
|
| Explain |
|
| |
|
By
checking the box below, I agree to authorize the agents
of Volunteer State Rescue Squad, INC. to investigate the
authenticity of the above data, with particular attention,
but not limited to, any past criminal history (omitting
events prior to age 18), traffic history and credit history.
Any falsification of data requested during any portion of
the application process could be considered grounds for
immediate termination of membership.
By checking this box, I agree further that in the event
I leave or am terminated from this agency, I will immediately
retur all issued equipment or equipment belonging to Volunteer
State Rescue Squad, INC. I fully understand that my participation
is probationary as set forth in the policies of this organization. |
| |
I AGREE |
