Online Membership Application

WATCHUNG RESCUE SQUAD

Application for Membership

Middle Initial

Please answer the following questions, If YES explain under remarks:

1. Have you ever been a member of another emergency service organization?                  Yes No

2. Has your driver's license ever been suspended in this or any other state?                      Yes No

3. Have you ever been convicted of a felony within the last 7 years?                                 Yes No

4. Do you have medical limitations which may prevent you from performing squad duties? Yes No

Remarks:

Do you have any of the following certifications:

1. Cardio-Pulmonary Resuscitation (CPR) Yes No  Expires:

2. Basic First Aid / First Responder Yes No  Expires:

3. Emergency Medical Technician (EMT) Yes No  Expires:

4. Hazardous Materials Yes No  Expires:

Active • Driver • Cadet Applicants

All Applicants

Monday  

Finance

Tuesday

Please provide two references (Not related to you):

Personal Evaluation forms will be sent to those listed below. The application process will continue upon their return:

1. Name:

     Street:

     Zip:   

Phone:   

2. Name:

     Street:

     Zip:   

Phone:   

Release and Consent

If accepted as a member of the Watchung Rescue Squad, I agree to abide by all rules and regulations set forth by the squad. I further agree that I will not divulge confidential information pertaining to squad calls, patient information, personnel, or business affairs of the squad.

I affirm that I do not have any illness, physical, or mental disorders that would prevent me from performing the assigned rescue squad duties. If requested, I will supply the names of any treating doctors, hospitals, or other medical facilities for medical conditions listed above. I will also consent to any random physical examination after age of 55, at the expense of the squad.

I certify that all the information on this application is true, that all pertinent information regarding driving privileges, criminal offenses, and medical information may be obtained by the squad and that a copy of this application may act as a release authorization form. Copies of any records will be retained by the squad and will be kept confidential. All original records will be returned after review by the Chairperson of the Membership Committee.

Full Name:

I accept the above statement

Parental Consent for Cadet Members

I hereby consent to allow my son/daughter to participate as a cadet member of the Watchung Rescue Squad.

Full Name:

I accept the above statement