Official Membership Application | Fredericksburg Rescue Squad

Official FRS Membership Application

Official Application for New Volunteers

Section 1: About You

Name(Required)

Your full legal name, as it appears on your taxes or driver's license

First Middle Last Suffix

Nickname

If you go by something different

Email(Required)

Phone(Required)

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Birthdate(Required)

Reason for joining(Required)

Emergency Contact (name and phone #)(Required)

Section 2: Certifications and Education

Current EMT cert?(Required)

EMT Cert State(Required)

Cert #(Required)

EMT Cert Expiration Date(Required)

Current EVOC cert?(Required)

EVOC Cert State(Required)

EVOC Expiration Date(Required)

CPR Certified?(Required)

CPR Expiration Date

FEMA Courses(Required)

List any FEMA, NIMS, HAZMAT, or other trainings here. Use the form below to upload copies of any certificates and supporting documentation

Driver's License Number(Required)

Enter N/A if you don't have a drivers license.

Drivers License State

Document Upload

Please upload any relevant documents for certifications, licensures, trainings, etc.

Supporting Documentation

Type of Document	Course Title / Training Name	Expiration	Upload Cert	Actions

There are no certs.

Upload copies of any licenses, certifications, relevant trainings, etc here

Graduated High School?(Required)

Name of High School

High School City, State

College, University or Vocational School

List name(s) of school(s) attended and degrees earned

Section 3: Experience and History

Have you ever been charged with Traffic Violation, Reckless Driving, Criminal Misdemeanor, or Felony?(Required)

Yes

If yes, an email will be sent to you for more information. If you answer yes, it will not necessarily exclude you from consideration.

Enter details: Date(s) and charge(s)

Do you have previous EMS experience at another agency?

Dates of Service

Still Associated?

Department Name and Address

Supervisor / Chief name and number

Your Duties at Previous Organization

Reason for Leaving Previous Organization

Have you ever applied to, or been a member of FRS?

Yes, I have applied in the past

Yes, I am a former member

Details: Date of application, or date(s) of service

Current Employment: Company name and address

If not currently employed, enter your last employer. Enter N/A if you have never been employed.

Your Supervisor, name, title and e-mail or phone number

List any workplace disciplinary actions and date(s)

Section 4: References

Personal Reference #1, name, title, and relation to you(Required)

This should be a friend, co-worker, or work supervisor

Personal Reference #1 Phone and Email(Required)

Personal Reference #2, name, title, and relation to you(Required)

This should be a friend, co-worker, or work supervisor

Personal Reference #2 Phone and Email(Required)

EMS Reference, name, title, and relation to you(Required)

This should be your supervisor at an EMS or Fire agency. Enter N/A if no previous EMS experience.

EMS Reference Phone and Email(Required)

Typed Signature(Required)

AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION I hereby authorize the view of and full disclosure of all records or any part thereof concerning myself, by and to any duly authorized agent of the Fredericksburg Rescue Squad, whether the said records are of a public, private or confidential nature. This authorization intends to give my consent for full and complete disclosure of all records- wherever located, which pertain to me. This authorization overrides any claim of privilege or confidentiality previously made by me or on my behalf. This authorization covers but is not limited to the following, which is by way of illustration and not by way of limitation: • Criminal records of complaint, arrest, trial, and/or convictions for alleged or actual violations of law, including criminal and traffic records (except records which a court has expunged); • Civil records of complaints of a civil nature made by or against me, wherever located (including records and recollections of attorneys-at-law or other counsel, whether representing another person or me in any case in which I presently have or had an interest). This authorization intends to provide full and unrestricted access to the background and history of my personal life for the specific purpose of pursuing a background investigation that may provide pertinent data for the Fredericksburg Rescue Squad to consider in determining my suitability for membership. The purpose of such research is to assess my character and personality as they pertain to my ability to perform the duties of the position to which I have applied. My specific intent is to provide access to personal information, however personal or confidential it may appear to be and the sources of information specifically listed above are not intended to deny access to any records not explicitly identified herein. I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this Release Authorization will be considered in determining my suitability for membership with the Fredericksburg Rescue Squad and I fully understand that a refusal to grant this authorization will not; of itself; constitute a basis for rejection of my application. TYPE YOUR FULL NAME BELOW: