Tri-Hampton Rescue Squad Volunteer Application

Applicant Personal Information

Last Name:      First Name: Middle Name:

Date of Birth: mm/dd/yyyy

Address: 

Address: 

City:          State:    ZIP:

Home Phone:    Cellular Phone:  Pager:

E-Mail Address:   

Name of Spouse: 

Emergency Contact Information

Last Name:  First Name: Phone:

Address:

Address:

City:        State:    ZIP:

Relationship:

Education And Training

High School Graduate:     Yes No   

 If Yes:    Name of High School:     Year of Graduation:   

GED:                             Yes No

 If Yes:    Name of State:             Year Issued:              

College, University, or Technical Schools Attended:

1 ) Name of Institution:     Dates Attended:

     Major:   Credits Received:   Degree:

2) Name of Institution:     Dates Attended:

     Major:    Credits Received:    Degree:

3) Name of Institution:     Dates Attended:

     Major:    Credits Received:    Degree:

 4) Name of Institution:     Dates Attended:

     Major:    Credits Received:    Degree:

Certifications

Driving Record

Drivers License Number: State:   Class:   Other Permits:

Restrictions:   Current Number of Points (if any):  

Has your license ever been revoked? Yes No

Are you an Emergency Driver at any other emergency service(s)?  Yes No

    If Yes: Where:   How Long:

General Information

Have you ever been convicted of a felony?  Yes No

            If yes, please give exact details (conviction, offenses, location of offense, sentencing court, date and nature of sentence.)

Do you wish to declare yourself handicapped? Yes No

        If yes, please describe nature:

Please indicate any allergies, health conditions or disabilities which may interfere with your ability to perform EMS.

Are you currently under a doctors care? Yes No

        If yes, explain and include physician's name and phone number:

In the past three years, have you knowingly used narcotics, amphetamines or barbiturates? Yes No

        If yes, explain:

Have you previously served in a volunteer emergency service? Yes No

        If yes:  Where:   When:

Do you have any military experience?  Yes No

        If yes: Branch: Length of Time:   Type of Discharge:

Please list any school honors, organization memberships unique skills etc.:

Please list any members of Tri-Hampton Rescue Squad that you know?

Please list any additional information you consider pertinent to your application for membership:

References (List Three)

1)    Name:   Home Phone:   Work Phone:

      Address:  City:    State: ZIP:

2)    Name:   Home Phone:   Work Phone:

      Address:  City:    State: ZIP:

3)   Name:   Home Phone:   Work Phone:

      Address:  City:    State: ZIP:

Other Information

Please indicate your desired area of service:

        Patient Care    Non Patient Care    Clerical    Trade (mechanical, computer, etc.) 

Is your availability year round? Yes No

        If no, when are you not available? 

Why are you interested in becoming a volunteer?

How did you learn about Tri-Hampton Rescue Squad?

To the best of your knowledge, will you be available to volunteer six months from the date of this application? Yes No

High School Students Only

Name of Parent or Legal Guardian:    

Home Phone:   Work Phone:

Address:  City:    State: ZIP:

Are you receiving School credit for your Volunteer Work? Yes No

        If yes, how many hours do you need to complete? 

Guidance Counselor's Name:   Phone: Year of Graduation:

Please Read the following carefully before continuing

We appreciate your interest in our organization. A clear understanding of your background and work history will aid us in considering you for a position in this organization.

1.  I give permission to Tri Hampton Rescue Squad to investigate any and all information concerning my application in      order to determine my qualifications. This includes, but is not limited to medical clearance, criminal background checks, employment and personal reference checks and educational or certification verification. I understand that any misrepresentation of facts contained in this application may cause for my rejection or dismissal.

2. I agree that any personal property carried by me during the course of duty may be inspected by authorized Rescue Squad Officers.

3. I agree to abide by all rules and regulations as described in The Operations Manual and/or Employee Manual, By-Laws and Standing Rules, and Directives. I understand that if placed, my placement will be subject to the condition of any applicable probationary period established by the Organization’s Policies. I understand that this application and any other Rescue Squad documents are not contracts of employment, and that any member who is placed may leave under proper notice, and may be terminated by the organization for cause.

4. In the event of resignation or termination, I agree to return all organizational property issued to me such as uniforms, identification, keys, etc.

By clicking the "apply" button below indicates that I have read, understand and consent to the above statements. The authorization or photocopy shall serve as a consent for the Tri Hampton Rescue Squad to request any information concerning my application.