Membership Application

Membership Application

Middlesex County Volunteer Rescue Squad
After filling out and submitting this form, you will receive a confirmation email, normally within minutes.

This confirmation email also includes important information regarding your next step: How to request the required Fieldprint Background Check.

Follow the procedure exactly as described!
You can start filling out this form and finish it up later if need be.

To do this:
- Make sure the email address field at the beginning of this form is filled out correctly
- Go to the bottom af this form and click "Save"
- A link for this form will appear that you can copy for later use AND an email with the same link is sent to the email address you have typed in at the beginning of the form.
- Click the link or copy the link and paste it into a web browser, and you will be directed back to this form to continue filling it out.
Name*

First NameMiddle NameLast Name
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email*
example@example.com
SS #
DOB*

MonthDayYear
Date
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address Is The Same*

YesNo
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Employment
Current Or Latest Employer *
Phone Number*
Please enter a valid phone number.
Occupation*
Length Of Employment*
Occupation Address*

Street Address

Street Address Line 2

CityState

Zip Code
Education
Highest Level of Education (Name and Location)*
Highest Grade Completed*
Degree Obtained*
Medical Training (e.g. nursing, emergency medical service, CPR, etc.)*
Do you hold a current, valid: Virginia OEMS Approved Provider Certification*

YesNo
Provider Certification #*
Provider Certification Expiration Date*

MonthDayYear
Date
Your Level Of Certification:*

EMT-FREMT-BEMT-AEMT-IEMT-POther
Do you hold a current, valid: Virginia Drivers License*

YesNo
Drivers License #*
Drivers License Expiration Date*

MonthDayYear
Date
Drivers License Endorsements and/or Restrictions*
Do you hold a current, valid: EVOC Certification*

YesNo
EVOC Certification Obtained From:*
EVOC Certification Date*

MonthDayYear
Date
Do you hold a current, valid: Provider level CPR Certification*

YesNo
CPR Certification #*
CPR Certification Issued By:*
CPR Issue Date*

MonthDayYear
Date
CPR Expiration Date*

MonthDayYear
Date
Do you have any physical or mental limitations?*

YesNo
If yes please provide details.*
Are you now, or have you ever been a member of a rescue squad or fire department?*

YesNo
If yes, name and location of rescue squad or fire department*
If no longer a member, why?*
Have you ever been denied membership in a rescue squad or fire department?*

YesNo
If yes, name and location of rescue squad or fire department and reason membership was denied.*
Have you ever been convicted of any crime, including driving violations?*

YesNo
If yes, state nature, date & location of offense*
Are you currently on probation for a criminal offense?*

YesNo
If you are on probation for a criminal offense, state the date your probation terminates*

MonthDayYear
Date

If accepted into the MCVRS, do you agree to:*

	Yes	No
Accept squad duty assignments of at least twenty four hours per month
Attend business meetings on the evening of the first Thursday each month
Attend scheduled training sessions on the evening of the first Thursday of each month, plus other classes as required to maintain certification at
Become certified as an EMT within eighteen (18) months or an EVOC qualified driver within twelve (12) months, depending upon availability of courses
Become CPR certified within twelve (12) months

Please provide two personal references:
NO FAMILY MEMBERS as references!
Reference 1 Name*

First NameLast Name
Reference 1 Address*

Street Address

Street Address Line 2

CityState

Zip Code
Reference 1, Phone Number*
Please enter a valid phone number.
How are you acquainted*
How long have you known this person*
Reference 2 Name*

First NameLast Name
Reference 2 Address*

Street Address

Street Address Line 2

CityState

Zip Code
Reference 2, Phone Number*
Please enter a valid phone number.
How are you acquainted*
How long have you known this person*
Signatures
I certify that the information given in response to the above questions is true and complete to the best of my knowledge, and I understand that any false or misleading information stated by me in this application or during subsequent interviews with the MCVRS Membership Committee may result in my application being denied or my membership being terminated.

I authorize the investigation of all information contained in this application, as well as my criminal and driving records which I understand are to become a part of this application.

I further understand that if I am approved for membership into the MCVRS, the initial membership will be for a probationary period of six to twelve months. After the first probationary period of six months, I will be evaluated for my performance and either accepted as a permanent member, extended for a second six month probationary period, or denied membership. If extended for another six month probation, I will be evaluated again at the end of the second probationary period and either accepted as a permanent member at that time or denied membership from the squad.
Applicant Signature*

Clear
Signed, Date*

MonthDayYear
Date
Type your full name*
I am under 18 years of age*

YesNo
If applicant is under 18 years of age, a Parent/Guardian must co-sign this application:
Parent/Guardian: Name*

First NameLast Name
Parent/Guardian: Signature*

Clear
Parent/Guardian: Signed, Date*

MonthDayYear
Date
Sponsoring Member: Name*

First NameLast Name
Sponsoring Member: Signature*

Clear
Sponsoring Member: Signed, Date*

MonthDayYear
Date
For MCVRS Use Only

Date Presented & Tabled________________________________________

Six Month Probationary Review Date_________Accepted Extended Denied

Twelve Month Probationary Review Date________Accepted Denied
Should be Empty:

Membership Application

Employment

Education

Please provide two personal references:

Signatures

If applicant is under 18 years of age, a Parent/Guardian must co-sign this application: