Please Complete the following application and Email to            mbrumlow@vsrescue.org

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Name: ________________________________  SS # ____________

Address:  _____________________________

City: ________________________  State:  ______  Zip: _________

Home Phone (____)___________   Cell Phone (____)___________

Age: _____        Date of Birth: _____________

 

Driver’s License # _________State _____  Type _____ Restrictions _______

Have you been convicted of moving traffic violation in the past 10 years? ______

If Yes, please explain________________________________________________

_______________________________________________________________

 

Employer: _____________________________  Occupation:______________

Address:  _____________________________Work Phone (____)__________

What hours available to respond to emergencies? _____________________

Will your employer allow you to leave in an emergency?  _______________

 

Prior Military Service  Branch:____________ Dates of Service:___________

 

Education (Please circle highest grade completed)   Elementary    5    6   7   8

High School   9   10   11   12   College   1   2   3   4   Post Grad   1   2   3   4  4+

College degree?  Major:  __________  Degree Type: __________

 

Have you ever been convicted of a crime?  (Check one)    ___ Yes    ___ No

If “Yes”, please explain________________________________________________

 

 

In Case of Emergency, whom would you like us to contact?

Name: ______________________________ Relationship: ________________

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Are you currently a member of any other rescue squad or fire department?  (Check one)    ___ Yes    ___ No

If “Yes”, please list  ________________________________________________

 

References: (non-relatives)

 

Name                                                                 Relationship:___________________

Address                                                            City/State/Zip: ___________________

Phone ________________________

 

Name                                                                 Relationship:___________________

Address                                                            City/State/Zip: ___________________

Phone ________________________

 

Skills     List any Medical, Rescue, Boat, Dive skills, date obtained, agency, cert. #’s:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Medical  Blood Type ____  Height _______ Weight ________ Allergies __________

Rescue operations may require the applicant to undergo periods of very strenuous physical activity.  If the answer to any of these questions is yes please explain below.

Have you ever had a serious injury?                                             YES ______          NO   _______

Have you ever had a hernia or rupture?                                       YES ______          NO   _______

Have you ever had back trouble of any kind?                             YES ______          NO   _______

Do you need to wear glasses at any time?                                  YES ______          NO   _______

Do you have any physical limitation that would prevent you from participating fully in rescue operations?                                                                                             YES ______          NO   _______

Do you take any medication or drugs on a regular basis        YES ______          NO   _______