APPLICATION FOR MEMBERSHIP
NAME:
DATE OF BIRTH:
ADDRESS:
PHONE (HOME):
PHONE (CELL):
E-MAIL ADDRESS:
BEST WAY TO CONTACT YOU? _______________________________________
HOW LONG AT ABOVE ADDRESS?
IF LESS THAN 5 YEARS LIST PREVIOUS ADDRESS:
SOCIAL SECURITY NUMBER:
DRIVER’S LICENSE NUMBER:
HAS YOUR LICENSE EVER BEEN REVOKED
OR SUSPENDED IN ANY STATE? N
Y
IF YES, WHEN AND WHY:
DO YOU HAVE ANY
MOVING VIOLATIONS?
HAVE YOU EVER HELD A DRIVER’S
LICENSE IN ANOTHER STATE?
HAVE YOU EVER
BEEN ARRESTED?
N
N
Y
Y
IF YES, CHARGE?
STATE OF ISSUE:
MUNICIPALITY?
IF YES, WHERE?
N
Y
STATE?
DISPOSITION?
NAME OF EMPLOYER:
EMPLOYER ADDRESS:
EMPLOYER PHONE:
HAVE YOU EVER BEEN A MEMBER
OF ANY VOLUNTEER ORGANIZATION?
ARE YOU CURRENTLY CERTIFIED IN:
(CIRCLE ALL THAT APPLY)
N
Y
CPR
IF UNDER 18, WHAT SCHOOL DO YOU ATTEND?
IF YES, WHERE AND WHEN?
FIRST AID
FIRST RESPONDER
EMT
LIST ONE TEACHER OR COUNSELOR WHO KNOWS YOU PERSONALLY:
DO YOU HAVE ANY DISABILITIES OR MEDICAL CONDITIONS?
N
Y
IF YES, EXPLAIN:
www.veronarescuesquad.org
MEMBER – NEW JERSEY STATE FIRST AID COUNCIL, SIXTH DISTRICT
(OVER)
HOW DID YOU HEAR ABOUT THE VERONA RESCUE SQUAD?
WHY DO YOU WANT TO JOIN THE VERONA RESCUE SQUAD?
LIST 3 REFERENCES BELOW (DO NOT INCLUDE RELATIVES)
1)
NAME:
PHONE:
ADDRESS:
HOW DO YOU KNOW THIS PERSON AND FOR HOW?
2)
NAME:
PHONE:
ADDRESS:
HOW DO YOU KNOW THIS PERSON AND FOR HOW LONG?
3)
NAME:
PHONE:
ADDRESS:
HOW DO YOU KNOW THIS PERSON AND FOR HOW LONG?
DO YOU HAVE ANY SPECIAL SKILLS OR INTERESTS?
HOURS AND DAYS OF AVAILABILITY TO VOLUNTEER WITH THE VERONA RESCUE SQUAD:
SUN_______________ MON______________ TUE________________ WED________________ THU_______________ FRI_______________ SAT________________
I AGREE THAT ALL INFORMATION I HAVE PROVIDED IS TRUE AND ACCURATE. I UNDERSTAND THAT FALSIFYING OR WITHHOLDING INFORMATION WILL
CAUSE REJECTION OF MY APPLICATION. I UNDERSTAND THAT MY INFORMATION WILL BE VERIFIED.
_______________________________________________________________________________________
APPLICANT’S SIGNATURE
_____________________________
DATE OF APPLICATION
TO THE PARENT OR GUARDIAN OF APPLICANT UNDER AGE 18:
I UNDERSTAND THAT MY CHILD IS APPLYING FOR MEMBERSHIP IN THE VERONA RESCUE SQUAD. I HEREBY CONSENT TO HAVE THE SQUAD PROCESS
THIS APPLICATION. IF MY CHILD IS APPROVED FOR MEMBERSHIP, I UNDERSTAND THAT I MUST ATTEND A MEETING WITH MY CHILD AND A
REPRESENTATIVE OF THE SQUAD PRIOR TO MY CHILD BEING APPROVED FOR MEMBERSHIP. I UNDERSTAND MY CHILD’S INFORMATION WILL BE
VERIFIED.
_______________________________________________________________________________________
PARENT / GUARDIAN SIGNATURE
DATE
_____________________________
_______________________________________________________________________________________
CHILD APPLICANT SIGNATURE
_____________________________
DATE
APPLICATION FOR MEMBERSHIP
(REVISED 02/08)
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