Application For Membership

 Name ____________________________________________________    Date ______________________

 Address __________________________________  City______________________________ State _____

 Date of Birth _____-_____-_____  Age _____  Sex:   Male   /   Female  Marital Status: _________________

 Home Telephone ____________________________  Work Telephone ____________________________

 Employer Name _____________________________  Address ___________________________________

 Supervisor _________________________________  Work Hours ________________________________

 Drivers License Number _______________________________  State ___________  Class ____________

 Email address __________________________________________________________________________

 Have you been convicted of a crime (other than a misdemeanor) within the last ten (10) years? _____________

 If yes, Please describe fully: _______________________________________________________________

 Social Security Number __________-_______-__________  Have you ever served in the military? ________

 Do you have any current medical training?    Paramedic    EMT-I    EMT    First Aid    CPR    _____________

 Why do you desire to become a member of the Aynor Rescue Squad? _______________________________
 
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 Could you regularly attend squad meetings? ( First & third Tuesday of each month) ______________________

 Could you be reached at work in case of an emergency rescue mission? ______________________________

 Could you leave work to perform a rescue mission in emergency cases? ______________________________

 Would you be willing to enroll in an EMT course within one year of membership? _______________________

 Would you perform your rescue duties in an orderly and professional manner? _________________________

 Would you obey the squad rules and regulations? _______________________________________________

 Type membership for which you are applying?              Regular             Associate             Junior

 Please read carefully and sign below

The facts given in this application are true and complete. I understand that if accepted, any  false statement on this application may result in dismissal. I also understand that all new members are under a six (6) months probationary period and can be terminated at any time with cause. I authorize the Aynor Volunteer Rescue Squad, Inc. to conduct background investigations into my personal, professional, financial, criminal, and character history for membership suitability. I agree to follow the policies, procedures, and directives of all officers, board of directors, and medical control physicians. The Aynor Volunteer Rescue Squad, Inc. generally provides each member with a building key, a radio pager for call notification, and possibly other equipment. I accept the responsibility to care for and secure any equipment provided to me and accept the financial responsibility for any equipment lost or negligently destroyed.

Any additional comments or information you wish to state.  ___________________________________________________________

 
 
Signature of applicant _____________________________________________________  Date ___________

 Notice: Any person wishing to join the Aynor Volunteer Rescue Squad must be recommended by a member in good standing. If any applicant does not personally know a member, they can come in person to the regular meetings held the first and third Tuesday of each month. Membership limits are set by the bylaws and an opening is not available at all times. Persons may be asked to submit to drug screening.

************  Do Not Write Below This Point  ************

Rescue Squad Comments Here !

 


 
 
Sponsor: _________________________________________________________  Date ____________

Approved          Disapproved          Membership Full

 

 Chief’s Signature ____________________________________________________  Date ____________

 

Copyright © 2010-1998 Aynor Volunteer Rescue Squad, Inc.