Lake Monticello Rescue Squad Membership Application

LMVRS

Application for


Contact Information


Emergency Contact Information



Education



Certification


Have you ever had your EMS certifications suspended, revoked or issued a citation from the Virginia Office of EMS or any other licensed agency? Yes No

Have you ever applied for or been a previous member of any other Rescue Squad or Fire Department? Yes No


Employment

Employment Status: Full Time Part Time Retired Unemployed




Previous Employment: Full Time Part Time


Virginia DMV / Criminal Convictions

Do you hold a current Virginia Driver’s License? Yes No

Have you ever had any traffic violations in the last five years? Yes No


Have you ever been convicted of a crime other than traffic violations? Yes No


Health

Do you have any condition that would prevent you from driving an Emergency Vehicle? Yes No

Are you taking any medication which would prevent you from operating on an Emergency Scene? Yes No


Personal References: (Please list names, addresses and telephone numbers of three (3) people who know you. Please do not list relative or former employers.)


Were you referred by a LMVRS member? Yes No

STATEMENT

I hereby certify that all information contained in this application is true and accurate. I understand that any information contained in this application which is found to be untrue or inaccurate will be grounds for my appointment to be rejected or, if appointed, withdrawn at any time without notice and that the only recourse that I may peruse is an appeal to the Board of Directors of Lake Monticello Volunteer Fire Department & Rescue Squad Inc. I also understand, that my appointment/membership may be revoked at any time by a majority vote of the Lake Monticello Volunteer Fire Department & Rescue Squad Inc. Board of Directors and that I will have no other appeal. I further agree to abide by the places and rules of the Corporation and its divisions. You must accept these terms to submit your application.

AUTHORIZATION

I authorize the use of any information in this application to enable the Lake Monticello Volunteer Fire Department & Rescue Squad Inc. (The Corporation) to verify statements made by me in this application and I authorize past employers, doctors, all references, and any other person to answer all questions asked by the Corporations concerning my ability, character, reputation and pervious employment records. I release all people who furnish information about me from any and all liability or damages on account of having furnished such information. You must authorize the use of these inputs to submit your application.

(Under Age 18 Years)

We the undersigned parents or guardian give permission for our son/daughter to become a member of the Lake Monticello Volunteer Rescue. We also accept responsibility for any equipment willfully destroyed by him/her. We further give permission for our son/daughter to ride in any Emergency Vehicle, to participate in emergency medical courses provided by this organization or other state or locally sponsored emergency services, and to submit to drug testing at the discretion of Lake Monticello Volunteer Rescue Squad.


A signed hard copy of this release will be required prior to final acceptance into the rescue squad.



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