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GENERAL INFORMATION

Last Name

First Name

Street Address

Apt #

City

State

Postal Code

Home Phone

Cell Phone

Driver's License

Emergency Contact

Phone

Employer/School

Occupation

Employer/School Address

City

State

Postal Code

PLEASE ANSWER THE FOLLOWING QUESTIONS. IF YES, PLEASE EXPLAIN UNDER REMARKS.

Have you ever been a member of another emergency services organization?	Yes	No
Have you ever been denied membership to another emergency services organiation?	Yes	No
Has your driver's license ever been suspended in this, or any other, state?	Yes	No
Have you ever received a moving violation and/or received points?	Yes	No
Do you have any medical limitation that may prevent you from performing duties?	Yes	No
Are you a United States citizen? If no, please state below.	Yes	No
Have you ever been convicted as a felon?	Yes	No
Have you ever been charged with a crime or been arrested?	Yes	No

Remarks

DO YOU HAVE ANY OF THE FOLLOWING CERTIFICATIONS?

Emergency Medical Technician (EMT)	Yes	No	Expires
Basic First Aid / First Responder	Yes	No	Expires
Cardiopulmonary Resuscitation (CPR)	Yes	No	Expires
Hazardous Materials	Yes	No	Expires
Incident Command System (ICS) (NIMS)	Yes	No
Weapons of Mass Destruction (WMD)	Yes	No

List All Other Pertinent Certifications

Have you ever served in the military? Yes No

If yes, pease elaborate upon your branch, experience, position, and discharge status.

PLEASE PROVIDE TWO REFERENCES (NOT RELATED TO YOU)

Name

Phone

Street Address

City

State

Postal Code

Name

Phone

Street Address

City

State

Postal Code

WHAT DAYS AND HOURS ARE YOU AVAILABLE FOR DUTY?

*Tours*	*Morning*	*Afternoon*	*Evening*	*Overnight*
Monday	6AM - 12PM	12PM - 6PM	6PM - 12AM	12AM - 6AM
Tuesday	6AM - 12PM	12PM - 6PM	6PM - 12AM	12AM - 6AM
Wednesday	6AM - 12PM	12PM - 6PM	6PM - 12AM	12AM - 6AM
Thursday	6AM - 12PM	12PM - 6PM	6PM - 12AM	12AM - 6AM
Friday	6AM - 12PM	12PM - 6PM	6PM - 12AM	12AM - 6AM
Saturday	6AM - 12PM	12PM - 6PM	6PM - 12AM	12AM - 6AM
Sunday	6AM - 12PM	12PM - 6PM	6PM - 12AM	12AM - 6AM

WHAT COMMITTEE(S) WOULD YOU LIKE TO SERVE ON?

Fundraising	Membership	Publicity
Building & Grounds	Vehicle Maintenance	Ambulance Supply

RELEASE AND CONSENT

IF ACCEPTED AS A MEMBER OF THE IRONBOUND AMBULANCE SQUAD, INC., I AGREE TO ABIDE BY ALL THE RULES AND REGULATIONS SET FORTH BY THE SQUAD. I FURTHER AGREE THAT I WILL NOT DIVULGE CONFIDENTIAL INFORMATION PERTAINING TO SQUAD CALLS, PATIENT INFORMATION, PERSONNEL, OR BUSINESS AFFAIRS OF THE SQUAD. I AFFIRM THAT I DO NOT HAVE ANY ILLNESS, PHYSICAL OR MENTAL DISORDERS THAT WOULD PREVENT ME FROM PERFORMING THE ASSIGNED AMBULANCE SQUAD DUTIES. IF REQUESTED, I WILL SUPPLY THE NAMES OF ANY TREATING DOCTORS, HOSPITALS, OR OTHER MEDICAL FACILITIES FOR MEDICAL CONDITIONS LISTED ON THE REVERSE SIDE OF THIS APPLICATION. I WILL ALSO CONSENT TO ANY RANDOM PHYSICAL EXAMINATION AFTER THE AGE OF 55. I CERTIFY THAT ALL THE INFORMATION ON THIS APPLICATION IS TRUE AND THE SQUAD MAY OBTAIN ALL PERTINENT INFORMATION REGARDING DRIVING PRIVILEGES, CRIMINAL OFFENSES, AND MEDICAL INFORMATION, AND THAT A COPY OF THIS APPLICATION MAY ACT AS A RELEASE AUTHORIZATION FORM. COPIES OF ANY RECORDS WILL BE RETAINED BY THE SQUAD AND WILL BE KEPT CONFIDENTIAL. THE CHAIRPERSON OF THE MEMBERSHIP COMMITTEE WILL RETURN ALL ORIGINAL RECORDS AFTER REVIEW.

Full Name of Applicant

Date

PARENTAL CONSENT FOR UNDERAGE MEMBERS

I HEREBY CONSENT TO ALLOW MY SON/DAUGHTER TO PARTICIPATE AS A JUNIOR MEMBER OF THE IRONBOUND SQUAD, INC. I AM AWARE THAT JUNIOR MEMBERS ARE NOT SUPERVISED AT ALL TIMES WHILE AT THE IRONBOUND AMBULANCE SQUAD BUILDING, AND REALIZE THAT JUNIOR MEMBERS ARE FREE TO COME AND GO OF THEIR OWN WILL.

Full Name of Parent/Guardian

Date