PO Box 1777 Louisa VA 23093

83 Rescue Lane Industrial Air Park Louisa VA

SUBJECT: APPLICATION FOR SENIOR VOLUNTEER RESCUE MEMBERSHIP

TO:__________________________________________________

__________________________________________________ Date:____________

Thank you for your interest in joining the rescue squad. In order to process your request for membership, you will find enclosed the following:

1. The application – please answer all items and write clearly.

2. Division of Motor Vehicle report request – complete the Subject’s Personal information & Subject’s Driving sections [both social & date of birth] located in the middle of the form. You must sign and date it for the request to be valid. Failure to return this form will delay your application process.

3. The references listed on your application will be contacted.

In addition to the above information, a criminal history will be requested from the Virginia State Police. After all required information has been gathered, you will be contacted and an appointment for the Membership Committee to meet with you will be arranged. Gathering the information may require a 30-day period.

Once your application has been received, it is presented to the membership at our regular monthly business meeting [the last week of each month] where it is tabled; action will be taken at the following monthly meeting. The Membership Committee will offer their recommendation, the members in attendance of the meeting will cast their vote on the application and you will be notified of the outcome.

We appreciate your interest in Louisa County Rescue Squad and the service you want to offer our community.

MEMBERSHIP APPLICATION FOR LOUISA COUNTY RESCUE SQUAD, INC. for:____________________________

Instructions:

1] Clearly print all of the requested information on this application in Sections I through 10.

2] Use the back pages of this application, or additional sheets which you initial, if needed to supply the requested information.

3] Sign the DMV Information Request form. It will be sent to DMV for a driving record from the State of Virginia or any state where you have held an operators license during the last 5 years.

4] All required information must be returned with this application. Inadequate, inaccurate or incomplete information may result in no action being taken on your request for membership or termination of your membership.

___Patient care provider ___Driver ___Administrative ___Board of Director

Name: _________________ _________________ _________________ _________________________ _________

First Middle Maiden [if applicable] Last Suffix

Date of Birth: Mo ___ Day ___ Year ___ SS#________________________ Drivers Lic #______________________

Home phone # [________] ________________________Work phone # [________] ________________________

Pager #: [________] ____________________ Cell Phone #: [________] ______________________________

Email: ____________________________________________________________________________________________

Mailing Address: __________________________________ Town/State/Zip/County:______________________________

Physical Location:_________________________________ Town/State/Zip/County:______________________________

If you have been at this address less than 3 years, list other addresses on the back of this page to include the length of time at each.

Have you ever used any other name? ___ Yes ___No If so, what?__________________________________

Have you ever used another ID or social security number & if so, what?_______________________________

Present/Last employer:________________________________________________________________________________

Employer address: ____________________________________________ Phone [ ]_____________________

City: _______________________ State:__________ Zip: ________ Occupation: ________________________

Date started: _____/_____/_____ Date left:_____/_____/_____ Supervisor:_________________________________

Membership application for:_______________________

A. Have you ever been a member of any rescue or fire organization? ____ Yes ____ No

If yes, list the dates, name[s] of the organization[s], address & phone number for each on the back of this page.

B. Have you ever resigned from, been rejected by or terminated from any rescue or fire organization? ____Yes ____No

If yes, describe the circumstances on the back of this page.

A. Are you licensed to drive in the State of Virginia? ____ Yes ____ No

B. Are you licensed to drive in a state other than Virginia? ____ Yes ____ No If yes, what state[s]:_______________

C. How many years of driving experience do you have?________________

D. Have you ever been charged with drunken or reckless driving? ____ Yes ____ No

If yes, give the details including the date, location of the offense & if convicted on the back of this page.

E. Have you ever been involved in a motor vehicle accident in which you were the driver? ____Yes ____ No

If yes, explain the circumstances [include the date and location] on the back of this page.

Describe your certifications, if applicable & provide copies of your certifications:

Certification/ID#

Expiration date

Name & Address of Instructor

CPR

EVOC

EMT

• The use of alcohol or the abusive use of prescription/non-prescription drugs during squad duty or prior to squad duty [such that it affects performance while on duty] is prohibited and subjects a squad member to immediate suspension or termination, at the discretion of the squad’s governing body.

• The information that you provide with this application shall be kept in the strictest confidence.

• Failure to accurately disclose all of the requested information may result in no action being taken on your application or termination of your membership.

• Criminal History Record will be requested from the Virginia State police.

A. Have you ever been charged with a felony crime? _____. If yes, give the details [including the date, location, if

if convicted] on the back of this page.

B. Do you use any habit forming drugs on a regular basis? _____. If yes, explain on the back of this page.

Membership application for:_______________________

D. Do you have or have you ever had any physical disabilities/impairments or other conditions, not limited to spinal, heart, vision, or hearing problems? _____ If yes, explain on the back of this page.

E. Are you or have you ever been under a physician’s care for any mental or nervous disorder? _____ If yes, explain on the back of this page.

F. Are you now on any long-term prescribed medication? _____ If yes, explain on the back of this page to include what and for how long.

G. What is your present physical condition? ___________________________________________________________

H. Date of last physical? _____/_____/_____

I. Name of your primary physician? _________________________________________________________________

Address & Phone Number: ______________________________________________________________________

Other than your statements in Section 8 above, do you know of any reasons [stress, tension, etc] why you should not drive an emergency vehicle or provide patient care?_______. If yes, explain on the back of this page.

List three references other than an employer, relative or present squad member:

1. Name:________________________________________________________________

Phone: [______] _________________ [home] [______] _________________ [work]

Address:______________________________________________________________

City:___________________________ State:______________ Zip:_________

2. Name:________________________________________________________________

Phone: [______] _________________ [home] [______] _________________ [work]

Address:______________________________________________________________

City:___________________________ State:______________ Zip:_________

3. Name:________________________________________________________________

Phone: [______] _________________ [home] [______] _________________ [work]

Address:______________________________________________________________

City:___________________________ State:______________ Zip:_________

Section 10

I hereby certify that the aforementioned information is true and correct to the best of my knowledge and do understand that providing false information in this application will disqualify me from membership. I further acknowledge that if my application is accepted I shall undergo a probationary period, as established by Louisa County Rescue Squad, Inc., and will abide by the By-Laws and Standard Operating Procedures of the LCRS, Inc.

Date:_____________________ Signature: ___________________________________________________