<p>APPLICATION FOR MEMBERSHIP</p><p>NAME: DATE OF BIRTH:</p><p>ADDRESS:</p><p>PHONE (HOME): PHONE (CELL): E-MAIL ADDRESS:</p><p>BEST WAY TO CONTACT YOU? ______HOW LONG AT ABOVE ADDRESS? IF LESS THAN 5 YEARS LIST PREVIOUS ADDRESS:</p><p>SOCIAL SECURITY NUMBER: DRIVER’S LICENSE NUMBER: STATE OF ISSUE:</p><p>HAS YOUR LICENSE EVER BEEN REVOKED IF YES, WHEN AND WHY: OR SUSPENDED IN ANY STATE? N Y</p><p>DO YOU HAVE ANY HAVE YOU EVER HELD A DRIVER’S IF YES, WHERE? MOVING VIOLATIONS? N Y LICENSE IN ANOTHER STATE? N Y</p><p>HAVE YOU EVER IF YES, CHARGE? MUNICIPALITY? STATE? DISPOSITION? BEEN ARRESTED? N Y</p><p>NAME OF EMPLOYER:</p><p>EMPLOYER ADDRESS:</p><p>EMPLOYER PHONE:</p><p>HAVE YOU EVER BEEN A MEMBER IF YES, WHERE AND WHEN? OF ANY VOLUNTEER ORGANIZATION? N Y</p><p>ARE YOU CURRENTLY CERTIFIED IN: CPR FIRST AID FIRST RESPONDER EMT (CIRCLE ALL THAT APPLY)</p><p>IF UNDER 18, WHAT SCHOOL DO YOU ATTEND? LIST ONE TEACHER OR COUNSELOR WHO KNOWS YOU PERSONALLY:</p><p>DO YOU HAVE ANY DISABILITIES OR MEDICAL CONDITIONS? N Y IF YES, EXPLAIN:</p><p> www.veronarescuesquad.org MEMBER – NEW JERSEY STATE FIRST AID COUNCIL, SIXTH DISTRICT (OVER) HOW DID YOU HEAR ABOUT THE VERONA RESCUE SQUAD?</p><p>WHY DO YOU WANT TO JOIN THE VERONA RESCUE SQUAD?</p><p>LIST 3 REFERENCES BELOW (DO NOT INCLUDE RELATIVES)</p><p>1) NAME: PHONE:</p><p>ADDRESS:</p><p>HOW DO YOU KNOW THIS PERSON AND FOR HOW?</p><p>2) NAME: PHONE:</p><p>ADDRESS:</p><p>HOW DO YOU KNOW THIS PERSON AND FOR HOW LONG?</p><p>3) NAME: PHONE:</p><p>ADDRESS:</p><p>HOW DO YOU KNOW THIS PERSON AND FOR HOW LONG?</p><p>DO YOU HAVE ANY SPECIAL SKILLS OR INTERESTS?</p><p>HOURS AND DAYS OF AVAILABILITY TO VOLUNTEER WITH THE VERONA RESCUE SQUAD:</p><p>SUN______MON______TUE______WED______THU______FRI______SAT______</p><p>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.</p><p>______APPLICANT’S SIGNATURE DATE OF APPLICATION TO THE PARENT OR GUARDIAN OF APPLICANT UNDER AGE 18:</p><p>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.</p><p>______PARENT / GUARDIAN SIGNATURE DATE</p><p>______CHILD APPLICANT SIGNATURE DATE</p><p>APPLICATION FOR MEMBERSHIP PAGE 2 (REVISED 02/08)</p>