Cobleskill Rescue Squad

Cobleskill Rescue Squad - Application

Please fill out the below information, we will be back in touch with you.
Name*

First NameLast Name
Social Security #*
DOB*
Age*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
DO YOU HOLD A VALID NYS LICENSE*
NYS Drivers License #*
License Class*
YESNO
IF NOT, PLEASE EXPLAIN THE GENERAL TIMES WHEN YOU ARE IN RESIDENCE:
YESNO
HAVE YOU BEEN CONVICTED OR CHARGED WITH ANY MISDEMEANOR IN THE LAST TEN YEARS RELATED TO SEX, ASSAULT OR VIOLENCE, DRUGS, THEFT OR FRAUD?IF YES, PLEASE EXPLAIN.
WHAT OR WHO HAS INTERESTED YOU IN JOINING THE RESCUE SQUAD?
WHAT ARE YOUR EXPECTATIONS OF THE SQUAD?
IN GENERAL, WHAT DAYS AND TIMES ARE YOU AVAILABLE?
DO YOU HAVE ANY HOBBIES, INTERESTS, OR SPECIAL SKILLS WHICH YOU FEEL MAY BE OF BENEFIT TO YOU IN YOUR WORK FOR THE RESCUE SQUAD?
YESNO
IF YES (to limitations), PLEASE EXPLAIN:
WHAT EMS CERTIFICATIONS DO YOU HOLD AT PRESENT, INCLUDING YOUR LAST CPR/FIRST AID, IF ANY? (Please upload a copy of CFR/EMT/AEMT Card with your application.)
Please list: LEVEL OF CERTIFICATION - CERTIFICATION NUMBER - CERTIFICATION EXPIRES
Upload a copy of CFR/EMT/AEMT Card here.

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ARE YOU CURRENTLY TAKING ANY EMS COURSES? LIST BELOW
Please List: 1. TYPE OF COURSE 2. COURSE LOCATION 3.COMPLETION DATE
HAVE YOU TAKEN ANY OTHER TYPE OF FIRE, EMS OR RELATED TRAINING? (E.g. Hazmat, Special Rescue courses, etc.) (Please upload a copy of any of these certificates.)
Please List TITLE OF PROGRAM and DATES
Please upload FIRE, EMS OR RELATED TRAINING Certificates.

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DO YOU HAVE ANY OTHER HEALTH RELATED CERTIFICATIONS/LICENSES?
Please List: 1. TYPE OF CERTIFICATION OR LICENSE 2. ISSUED BY 3.EXPIRES
PLEASE LIST THE PERSON TO BE NOTIFIED IF YOU BECOME ILL OR INJURED WHILE VOLUNTEERING FOR THE RESCUE SQUAD:
Emergency Notification Name*

First NameLast Name
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Relationship:*
Daytime - Cell Phone
Please enter a valid phone number.
Evening Phone
Please enter a valid phone number.
PLEASE LIST THE NAMES AND ADDRESSES OF TWO PERSONAL REFERENCES
(No relatives please)
Reference #1 Name*

First NameLast Name
Reference #1 Phone Number*
Please enter a valid phone number.
Reference #1 Relationship
Reference #1 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference #2 Name*

First NameLast Name
Reference #2 Phone*
Please enter a valid phone number.
Reference #2 Relationship
Reference #2 Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PLEASE LIST NAMES AND ADDRESSES OF ALL EMS OR HEALTH-RELATED ORGANIZATIONS/AGENCIES FOR WHICH YOU HAVE BEEN EMPLOYED OR VOLUNTEERED
Agency #1 Name   Address   Address Line 2   City   State   Zip

Area Code   Phone Number      Job Title   Supervisor Name
Job Title    Dates of Employment
Agency #1 Name   Address   Address Line 2   City   State   Zip

Area Code   Phone Number      Job Title   Supervisor Name
Job Title    Dates of Employment
Agency #1 Name   Address   Address Line 2   City   State   Zip

Area Code   Phone Number      Job Title   Supervisor Name
Job Title    Dates of Employment
I, THE APPLICANT WHOSE NAME APPEARS BELOW THIS STATEMENT, ACKNOWLEDGE THAT THE INFORMATION I HAVE GIVEN IN THE ABOVE APPLICATION IS COMPLETE AND TRUTHFUL TO THE BEST OF MY KNOWLEDGE.

I HEREBY APPLY FOR MEMBERSHIP IN THE RESCUE SQUAD. I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE STANDARD OPERATING POLICIES AND PROCEDURES OF THE ABOVE-NAMED AGENCY, AND IF, ACCEPTED AS A MEMBER, AGREE TO ABIDE BY THE BYLAWS AND STANDARD OPERATING POLICIES AND PROCEDURES.

I HEREBY CERTIFY THAT I HAVE NO MEDICAL OR OTHER CONDITIONS THAT WOULD PREVENT ME FROM FULFILLING THE RESPONSIBILITIES OF THE POSITION FOR WHICH I AM APPLYING, AS SPECIFIED IN THE JOB DESCRIPTION.

I AUTHORIZE ALL PREVIOUS EMPLOYERS, FIRE DEPARTMENTS OR RESCUE SQUADS OF WHICH I HAVE BEEN A MEMBER, TO RELEASE ANY INFORMATION REGARDING MY WORK RECORD, PROFESSIONAL QUALIFICATIONS, AND CHARACTER.
Signature*

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Date Signed*

MonthDayYear
Date
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Cobleskill Rescue Squad - Application