Goshen First Aid Crew
9770 Maury River Rd, Goshen, VA, 24439
Goshenfirstaid@gmail.com
www.goshenfirstaid.com
(540) 997-9409
GFAC Senior Crew Application
Fill out the form below. We will review it at the next meeting (Second Wednesday of every month) and we will contact you if you are accepted or not.
Demographics
Name
*
First Name
Last Name
Date of Birth
*
Please select a day
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Day
Please select a month
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Month
Please select a year
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Year
Gender
*
Please Select
Male
Female
Non-binary
Other/Do not wish to disclose
Phone Number
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different from above address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employment Information (if unemployed type "N/A")
*
Employer
Job Title
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor's Name
First Name
Last Name
Supervisor's Phone Number
Please enter a valid phone number.
Supervisor's Email
example@example.com
May we contact this employer?
Yes
No
What is your highest level of education completed?
*
Elementary/Primary School (Grades Preschool through 5)
Middle School (Grades 6-8)
High School (Grades 9-12)
High School Graduate/GED
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
Doctorate Degree
Are you currently enrolled at as a student at any educational institute?
*
Yes
No
If yes, where do you attend courses and what level of education are you working on?
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Cell Phone Number
*
Please enter a valid phone number.
Emergency Contact Email
*
example@example.com
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Next
General Infomation
Do you have a valid Drivers License or State ID?
*
Yes
No
Driver's License/State ID Number
*
Front and Back Pictures of Driver's License/State ID
*
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Have you been convicted of any driving offense?
*
Yes
No
Have you been convicted of a felony?
*
Yes
No
Have you been convicted of sexual offense?
*
Yes
No
Have you been asked to resign or terminated from an employer or volunteer agency due to misconduct or harassment?
*
Yes
No
Have you been found guilty of neglect or abuse of any kind of an adult, child, or animal?
*
Yes
No
Do you currently have any pending judicial hearings that you are awaiting trial or sentencing for?
*
Yes
No
Have you ever had a substance abuse problem?
*
Yes
No
Do you have any physical disability? (This will not make you ineligible for membership)
*
Yes
No
Are you a veteran?
*
Yes
No
If yes to any questions above, please explain in detail.
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Miscellaneous
Please select any certifications or licensures that apply to you.
*
CPR/BLS
EMR
EMT
AEMT
EMT-I
EMT-P
EVOC
None
Other
If you selected other, please list below.
Please attach any licensures or certifications.
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Have you ever had a certification or licensure, including driver's license, suspended or revoked?
*
Yes
No
If yes, please explain in detail.
Are you willing to take further training that may or may not be at your expense?
*
Yes
No
If yes, what training/certification are you interested in?
Will you help out with fundraising events and community outreach events?
*
Yes
No
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References
Please list two professional references and one personal reference.
Name
*
First Name
Last Name
Relationship
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Name
*
First Name
Last Name
Relationship
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Name
*
First Name
Last Name
Relationship
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Please list any memberships you have to other agencies, groups, or organizations. (If you do not have any memberships, please type "N/A")
*
Please list any additional information you would like to provide.
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