Aynor Volunteer Rescue Squad, Inc.

Name ____________________________________________________ Date ______________________

Address __________________________________ City______________________________ State _____

Date of Birth _____-_____-_____ Age _____ Sex: Male / Female Marital Status: _________________

Home Telephone ____________________________ Work Telephone ____________________________

Employer Name _____________________________ Address ___________________________________

Supervisor _________________________________ Work Hours ________________________________

Drivers License Number _______________________________ State ___________ Class ____________

Email address __________________________________________________________________________

Have you been convicted of a crime (other than a misdemeanor) within the last ten (10) years? _____________

If yes, Please describe fully: _______________________________________________________________

Social Security Number __________-_______-__________ Have you ever served in the military? ________

Do you have any current medical training? Paramedic EMT-I EMT First Aid CPR _____________

Why do you desire to become a member of the Aynor Rescue Squad? _______________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Could you regularly attend squad meetings? ( First & third Tuesday of each month) ______________________

Could you be reached at work in case of an emergency rescue mission? ______________________________

Could you leave work to perform a rescue mission in emergency cases? ______________________________

Would you be willing to enroll in an EMT course within one year of membership? _______________________

Would you perform your rescue duties in an orderly and professional manner? _________________________

Would you obey the squad rules and regulations? _______________________________________________

Type membership for which you are applying? Regular Associate Junior

The facts given in this application are true and complete. I understand that if accepted, any false statement on this application may result in dismissal. I also understand that all new members are under a six (6) months probationary period and can be terminated at any time with cause. I authorize the Aynor Volunteer Rescue Squad, Inc. to conduct background investigations into my personal, professional, financial, criminal, and character history for membership suitability. I agree to follow the policies, procedures, and directives of all officers, board of directors, and medical control physicians. The Aynor Volunteer Rescue Squad, Inc. generally provides each member with a building key, a radio pager for call notification, and possibly other equipment. I accept the responsibility to care for and secure any equipment provided to me and accept the financial responsibility for any equipment lost or negligently destroyed.

Any additional comments or information you wish to state. ___________________________________________________________

Signature of applicant _____________________________________________________ Date ___________

Notice: Any person wishing to join the Aynor Volunteer Rescue Squad must be recommended by a member in good standing. If any applicant does not personally know a member, they can come in person to the regular meetings held the first and third Tuesday of each month. Membership limits are set by the bylaws and an opening is not available at all times. Persons may be asked to submit to drug screening.

Sponsor: _________________________________________________________ Date ____________

Chief’s Signature ____________________________________________________ Date ____________