Mechanicsville Volunteer Rescue Squad, Inc. Company 29 P.O. Box 15, Mechanicsville, MD

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1 Mechanicsville Volunteer Rescue Squad, Inc. Company 29 P.O. Box 15, Mechanicsville, MD APPLICATION FOR MEMBERSHIP Please print in ink. All information submitted is subject to verification. A false statement may result in disqualification for membership either now or at a later date. TYPE OF APPLICATION: New Reinstatement from Inactive Membership TYPE OF MEMBERSHIP APPLYING FOR: (Please check one) Cadet (age 14 & 15) Driver only (age 21 & up) Active (age 18 & up with EMT-B Certification or Higher) Administrative (age16 & up) Provisional (age 16 & 17 with 1 st Responder or higher; or age 18 or higher with EMR) Associate (current member at another rescue/fire dept. in Tri-County with EMR or higher) PLEASE PROVIDE ALL REQUESTED INFORMATION. FAILURE TO PROVIDE COMPLETE INFORMATION CAN RESULT IN DELAYS PROCESSING YOUR APPLICATION AND MEMBERSHIP. PERSONAL INFORMATION Name: Last First Middle (Jr/Sr/III) Social Security Number: - - Date of Birth: / / (MM/DD/YEAR) Address: City: State: Zip: Phone: Home Cell Work

2 Marital Status (check one): Single Married Widowed Divorced DRIVER S LICENSE: Do you have a Driver s License? YES NO Driver s Licenses Number: Class: State issued: Have you ever been convicted or posted collateral/bail for any traffic violation? YES NO If yes, list all such offenses with date, place, and action taken. EMERGENCY INFORMATION: Who can we contact for you in case of an emergency? Name Relationship Phone BACKGROUND INFORMATION: A signed Volunteer Employment Consent/Release Form by St. Mary s County Volunteer Emergency Services is required when this application is received and tabled at the meeting. The form is attached. Have you ever been convicted of a misdemeanor or felony or are you under charge(s) for a misdemeanor or felony? YES NO If yes, list all offenses and state date, place and action taken: TRAINING: Please submit copies of any certifications you hold for any EMS/Fire Training and course work completed including dates of completion and/or expiration.

3 ADDITIONAL RESCUE SQUAD/EMS/ALS/FIRE INFORMATION Are you a member of another Rescue Squad, EMS, ALS or Fire Department? YES NO Have you ever been a member of another Rescue Squad, EMS, ALS or Fire Department? YES NO Has your service in any Rescue Squad, EMS, ALS or Fire Department organization been terminated for any reason other than retirement or VOLUNTARY resignation? YES NO If yes, explain: Attach a list of all Rescue Squad, EMS, ALS or Fire Department organizations s to which you were either a paid and/or volunteer member. Include date (from/to), and any offices held. EMPLOYMENT: Are you currently employed? YES NO Place of Employment: HEALTH/PHYSICAL Applicants will be required to submit a completed MVRS Health History, Physician Review and Certification Fitness for Duty form. Your physician will need to sign the form. If the form is not attached to this application, you can print the form from the internet by going to find In the Community and click on Recruitment and then click on Health Form.

4 PLEASE READ CAREFULLY By submitting this application for membership in the Mechanicsville Volunteer Rescue Squad, Inc. (MVRS), I authorize investigation of all statements contained therein. I hereby authorize MVRS to make any contacts considered necessary for me to become a member, such as current employers, criminal records, etc. It is understood and agreed that any misrepresentation by me in this application, will be sufficient cause for cancellation of the application or for separation from MVRS as a member at any time. I understand that this application is the property of Mechanicsville Volunteer Rescue Squad, Inc. and will become part of my personnel file if I am accepted as a member. Driver record checks may be required in accordance with MVRS insurance carrier s requirements. I hereby authorize MVRS to obtain my complete driving history. POLICY STATEMENT: MVRS is an equal opportunity organization and shall not discriminate against any member or applicant due to age, sex, marital status, national origin, religion, race, physical or mental handicap unrelated to the performance of the job or any other prohibited reasons. The Membership Committee will review this application and additional information developed during background checks. Applicants may be disqualified for criminal conduct. I, here by acknowledge that I have read the above statement and certify that all information contained within this application to be true and correct to the best of my knowledge. Signature Date If applicant is less than 18 years of age, a parent or legal guardian MUST sign this application. Parent or Legal Guardian Signature Witness Signature

5 Consent/Release Form St. Mary s County Volunteer Emergency Services Applicant s Full Name (Print) Social Security Number: Date of Birth: Applicant s Address: City: State: Zip: I,, authorize and give consent for Mechanicsville Volunteer Rescue Squad, Inc. to obtain my background information. Including the following: Criminal background records/information Sex Offender Registry Checks Addresses I the undersigned, authorize this information to be obtained either in writing or via telephone in connection with my application. Any person, firm or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with St. Mary s County guidelines. Print Name: Date: Signature:

6 HELP US ATTRACT MORE VOLUNTEERS Thank you for applying to MVRS for membership. Please take a few more minutes and tell us how you decided to apply to us for membership. This information will be used to improve our recruitment and St. Mary s County Volunteer Recruitment. Tell us how you heard about Mechanicsville Volunteer Rescue Squad: Friends Family Radio Ad News Paper MVRS member recruited you St. Mary s County Volunteer Recruiter Recruiting Event, which event? Other, please list How did you get our application? Received from MVRS Station MVRS Website St. Mary s County Volunteer Recruiter Event, please list event Any other comments on how to improve recruitment, please tell us in the space below: