CCVRS Membership Application Updated

Welcome to the Charles County Volunteer Rescue Squad's online membership application. Please complete all questions fully and thruthfully.

After you application is received, you will be contacted to set up an interview and provided additional information about the membership process.

Volunteer Acknowledgement - I understand that I am applying for membership in a volunteer organization and that while there are benefits to becoming a member, I will not receive a salary or hourly pay.*

I acknowledge and understand the above

Location Acknowledgement - I understand that the Charles County Vol. Rescue Squad is located in La Plata, Maryland, and primarily serves the town and outlying neighborhoods. For a list of other Charles County departments that may be closer to you, please visit: https://www.ccvfireems.org/content/companies*

I acknowledge and understand the above

Date*

Date

Full Name*

Date of Birth*

Date

Age*

Height*

Weight*

Address*

City*

State*

Zip*

Email*

example@example.com

Phone (Mobile)*

Employer or School Attending*

Occupation*

Type of Membership Appying For (check one below)

Active Membership: Active Members will be required to obtain CPR certification and will be required to enroll in an Emergency Medical Technician (EMT) class or hold current EMT certification or higher. Active members can also function as drivers after completing Emergency Vehicle Operator Training (EVOC).

Driver Membership: Driver Members are not required to enroll in the Emergency Medical Technician course. Driver members are required to complete Emergency Vehicle Operator Training (EVOC), hold a current commercial driver's license, or be an active police officer. Driver members are required to obtain CPR certification and assist EMTs with medical care as an aide.

Administrative/Auxiliary Membership: Administrative/Auxiliary members are non-riding members. These members help with fundraising, miscellaneous committees, and other administrative functions.

Type of Membership

Active MembershipDriver MembershipAdministrative/Auxillary

The physical demands described here are representative of those that must be met by a volunteer to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job the volunteer will frequently be required to stand, walk, use hands and fingers, handle or operate objects, tools, controls and equipment as well as reach with arms and hands. Additionally, the volunteer is frequently required to sit, climb or balance, stoop, kneel, crouch or crawl, talk, read, hear and smell and/or taste. This job requires a high level of physical demand and may place you in close contact with persons with infectious diseases.

The volunteer must frequently lift and/or move up to 25 pounds and occasionally lift and/or move up to 100 pounds and may, from time to time, have to lift and/or move over 200 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth vision and the ability to adjust focus.

Are you now, or have you ever been, a member of any paid or volunteer Fire Department or Rescue Squad? If yes, please list department(s), location(s) and dates of membership or employment below.*

YesNo

Previous Memberships/Dates

Have you ever received LOSAP from another company in Charles County? If yes, please list the company, as well as which company will be handling your LOSAP reporting.*

YesNo

LOSAP Information

Are you now, or have you ever been, suspended, terminated, or refused membership and or employment from a Fire Department or Rescue Squad? If yes, please give reason below.*

YesNo

Additional Information

Have you ever had any Fire Department, First Aid, or EMT training? If yes, list the training you’ve passed and the location(s) where instructed.*

YesNo

Previous Training

Do you currently have a valid Driver’s Licenses? If yes, please provide the number, State, and expiration date.

Driver's License Number

State

Exp Date

Date

Have you ever been convicted of a Motor Vehicle Violation? If yes, list violation(s) below.

Have you ever been convicted of a crime, major (must appear) traffic violations, or any PENDING criminal charges? If yes, please explain. You may include location, dates and disposition of the crime. All potential members are required to submit to a background investigation.*

YesNo

Additional Information

Emergency Contact Name*

Relationship*

Address*

City*

State*

Zip*

Emergency Contact Phone Number*

Please enter a valid phone number.

I certify that I have read and understand the Physical Demands of this membership and also certify that the statements made by me in this application are true, complete and correct to the best of my knowledge and belief. If accepted, I will abide by the By-Laws and all rules and regulations set forth by this organization.

Signature of Applicant*

Date*

Date

Note:

If you are uner 18 years of age (the minimum age to join is 16) your parent/guardian will be required to sign permission for you to join, in person, at the date of your interview.

You must be recommended by the Application Committee before having your application presented to, and then voted upon, by the general membership. This recommendation is based upon conclusions derived by this committee during an interview which must be conducted prior to the application being presented to the general membership at a regular monthly business meeting. This application must be submitted to the Secretary of the Squad at a regular business meeting, but will not be voted on until the following business meeting. The applicant must be present atthe business meeting in which the membership is to vote on the application. If the applicant fails to show for two consecutive business meetings after initially submitting their application, then the application will be dropped due to lack of interest. After the application is presented to the membership at a regular monthly business meeting, the applicant is encouraged to come to the squad and become familiar with the members and the apparatus. New applicants or members may not run calls until they have successfully completed a CPR/AED course, if not already certified, and completed the ambulance orientation and received approval from an Operational Officer.

The officers and members of the Charles County Volunteer Rescue Squad request a criminal record check on the member applicant whose name appears below.

Do you have any PENDING criminal or MUST APPEAR traffic violations?

YesNo

Have you ever been convicted of any crime?

YesNo

Have you ever been convicted of any major traffic violations that require an appearance in court? (DUI/DWI, driving while suspended, failure to stop, etc.)

YesNo

If yes to any of the above, please explain:

I authorize the Charles County Volunteer Rescue Squad to conduct a criminal record search on me. I agree that all statements are truthful and complete.

Signature of Applicant*

Charles County Volunteer Rescue Squad - Membership Application

Applicant Acknowledgements

Personal Information

Membership Type

Physical Demands

Applicant Questions

Emergency Contact Information

Membership Agreement

REQUEST FOR CRIMINAL RECORDS CHECK