Washington Emergency Squad Member Application

Date

Name

Street City State AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC TN TX UT VT VA WA WV WI WY Zip

How long at current address Years / Months

Home Phone Work Phone Cell Phone

Social Security Number Date of Birth Age

Marital Status: Married Single Divorced Separated Widow(er)

Name

Street City State AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC TN TX UT VT VA WA WV WI WY Zip

Home Phone Work Phone Cell Phone

Have you ever been convicted of a felony? Yes No

If yes, please explain:

Have you ever been convicted of a disorderly person? Yes No

If yes, please explain:

Have you ever been convicted of drunk driving? Yes No

If yes, please explain:

Do you have a drivers license? Yes No State of issue: AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC TN TX UT VT VA WA WV WI WY

Do you drive Yes No How long have you been driving Years

Drivers License # Expiration date

Do you have any points? Yes No Total # of points None 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 More than 15

If yes, please explain:

1. Name of Employer Contact

Dates of employment to Occupation

Address Phone #

Normal work hours to

2. Name of Employer Contact

Dates of employment to Occupation

Address Phone #

Normal work hours to

3. Name of Employer Contact

Dates of employment to Occupation

Address Phone #

Normal work hours to

Do you have any experience in first aid/rescue field? Yes No

If yes, please explain:

Name of organization

Address How long were you a member

Contact name Phone #

Card valid:

EMT Expiration date
CPR(AHA or ARC) Expiration date

Were/are you in the military Yes No from to

Branch Rank attained Honorable discharge

MOS Are you in the Reserves? Yes No

Have you ever been treated for the following?

If yes, please explain and provide dates:

Do you now have or at any time had a dependency on Alcohol Drugs

Are you presently taking any medications? Yes No

If yes, please explain:

Please list a primary and secondary emergency contact

Primary Name Phone #

Secondary Name Phone #

Why do you want to join the Washington Emergency Squad?

How did you find out about the Washington Emergency Squad?

What hours would you normally be available to answer calls?

Do you have any physical problems that would hamper you in squad activities?

1. Name

Street City State AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC TN TX UT VT VA WA WV WI WY Zip

Phone # Relationship

2. Name

Street City State AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC TN TX UT VT VA WA WV WI WY Zip

Phone # Relationship

3. Name

Street City State AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC TN TX UT VT VA WA WV WI WY Zip

Phone # Relationship

I, the undersigned, realize that this application to the Washington Emergency Squad does not mean automatic acceptance. Further, if acceptance is obtained under this application, I agree to submit to a physical examination. The answers to the foregoing are true to the best of my knowledge and belief. I understand that any false statements on this application is sufficient cause for rejection or dismissal.

Signature: _______________________________________________Date_____________________
(Parent Signature if under 18)

School records released for Junior Member Applicants

I authorize the release of my child's school records to the Trustees of the Washington Emergency Squad

Parent Signature:__________________________________________Date_____________________