Verona Rescue Squad

APPLICATION FOR MEMBERSHIP

NAME: DATE OF BIRTH:

ADDRESS:

PHONE (HOME): PHONE (CELL): E-MAIL ADDRESS:

BEST WAY TO CONTACT YOU? ______HOW LONG AT ABOVE ADDRESS? IF LESS THAN 5 YEARS LIST PREVIOUS ADDRESS:

SOCIAL SECURITY NUMBER: DRIVER’S LICENSE NUMBER: STATE OF ISSUE:

HAS YOUR LICENSE EVER BEEN REVOKED IF YES, WHEN AND WHY: OR SUSPENDED IN ANY STATE? N Y

DO YOU HAVE ANY HAVE YOU EVER HELD A DRIVER’S IF YES, WHERE? MOVING VIOLATIONS? N Y LICENSE IN ANOTHER STATE? N Y

HAVE YOU EVER IF YES, CHARGE? MUNICIPALITY? STATE? DISPOSITION? BEEN ARRESTED? N Y

NAME OF EMPLOYER:

EMPLOYER ADDRESS:

EMPLOYER PHONE:

HAVE YOU EVER BEEN A MEMBER IF YES, WHERE AND WHEN? OF ANY VOLUNTEER ORGANIZATION? N Y

ARE YOU CURRENTLY CERTIFIED IN: CPR FIRST AID FIRST RESPONDER EMT (CIRCLE ALL THAT APPLY)

IF UNDER 18, WHAT SCHOOL DO YOU ATTEND? LIST ONE TEACHER OR COUNSELOR WHO KNOWS YOU PERSONALLY:

DO YOU HAVE ANY DISABILITIES OR MEDICAL CONDITIONS? N Y IF YES, EXPLAIN:

www.veronarescuesquad.org MEMBER – NEW JERSEY STATE FIRST AID COUNCIL, SIXTH DISTRICT (OVER) HOW DID YOU HEAR ABOUT THE VERONA RESCUE SQUAD?

WHY DO YOU WANT TO JOIN THE VERONA RESCUE SQUAD?

LIST 3 REFERENCES BELOW (DO NOT INCLUDE RELATIVES)

1) NAME: PHONE:

ADDRESS:

HOW DO YOU KNOW THIS PERSON AND FOR HOW?

2) NAME: PHONE:

ADDRESS:

HOW DO YOU KNOW THIS PERSON AND FOR HOW LONG?

3) NAME: PHONE:

ADDRESS:

HOW DO YOU KNOW THIS PERSON AND FOR HOW LONG?

DO YOU HAVE ANY SPECIAL SKILLS OR INTERESTS?

HOURS AND DAYS OF AVAILABILITY TO VOLUNTEER WITH THE VERONA RESCUE SQUAD:

SUN______MON______TUE______WED______THU______FRI______SAT______

I AGREE THAT ALL INFORMATION I HAVE PROVIDED IS TRUE AND ACCURATE. I UNDERSTAND THAT FALSIFYING OR WITHHOLDING INFORMATION WILL CAUSE REJECTION OF MY APPLICATION. I UNDERSTAND THAT MY INFORMATION WILL BE VERIFIED.

______APPLICANT’S SIGNATURE DATE OF APPLICATION TO THE PARENT OR GUARDIAN OF APPLICANT UNDER AGE 18:

I UNDERSTAND THAT MY CHILD IS APPLYING FOR MEMBERSHIP IN THE VERONA RESCUE SQUAD. I HEREBY CONSENT TO HAVE THE SQUAD PROCESS THIS APPLICATION. IF MY CHILD IS APPROVED FOR MEMBERSHIP, I UNDERSTAND THAT I MUST ATTEND A MEETING WITH MY CHILD AND A REPRESENTATIVE OF THE SQUAD PRIOR TO MY CHILD BEING APPROVED FOR MEMBERSHIP. I UNDERSTAND MY CHILD’S INFORMATION WILL BE VERIFIED.

______PARENT / GUARDIAN SIGNATURE DATE

______CHILD APPLICANT SIGNATURE DATE

APPLICATION FOR MEMBERSHIP PAGE 2 (REVISED 02/08)