Mechanicsville Volunteer Rescue Squad, Inc.




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Application for Membership

Required   Indicates Required Field
Application Info
Date/Time: 01/19/2019 2043
Type of Application: Required New
Reinstatement from Inactive Membership
Check Membership Applying for: Required Cadet (age 14 & 15)
Active (age 18 & up with EMT-B Certification or Higher)
Driver only (age 21 & up)
Administrative (age16 & up)
Provisional (age 16 & 17 with 1st Responder or higher; or age 18 or higher with EMR)
Associate (current member at another rescue/fire dept. in Tri-County with EMR or higher)
Personal Information
First Name: Required
Middle Initial: Required
Last Name: Required
Date of Birth: Required
Address: Required
City: Required
State: Required
Zip: Required
Telephone: Required
E-mail Address: Required
Marital Status: Required Single
Married
Widowed
Divorced
Additional Information
Do you have a Driver's License?: Required Yes
No
Number:
Class:
State Issued:
Have you ever been convicted or posted collateral/bail for any traffic violation: Required Yes
No
If yes, list all such offences with date, place, and action taken:
Emergency Contact
Contact Name: Required
Contact Relationship: Required
Contact Phone: Required
Background Information (A signed Volunteer Employment 'Consent/Release Form' by St. Mary's County Volunteer Emergency Services is required when this application is received and tabled at the meeting.)
Have you ever been convicted of a misdemeanor or felony or are you under charge(s) for a misdemeanor or felony?: Required Yes
No
If yes, list all offenses and state date, place and action taken:
Training (Please submit copies of any certifications you hold for any EMS/Fire Training and course work completed including dates of completion and/or expiration.)
Please Include all training Including (Training Level) (MFRI / MIEMSS I.D. Number) (Completed or Expiration Date):
Please add copies of your certifications here:
Add files...
Employment
Are you currently employed : Required Yes
No
Place of Employment:
ADDITIONAL RESCUE SQUAD/EMS/ALS/FIRE INFORMATION
Are you a member of another Rescue Squad, EMS,ALS or Fire Department?: Required Yes
No
Have you ever been a member of another RescueSquad, EMS, ALS or Fire Department?: Required Yes
No
If yes, explain:
Attach a list of all Rescue Squad, EMS,ALS or Fire Department organizations to which you were either a paid and/or volunteer member. Include date (from/to), and any offices held:
Please read Carefully By submitting this application for membership in the Mechanicsville Volunteer Rescue Squad, Inc. (MVRS), I authorize investigation of all statements contained therein. I hereby authorize MVRS to make any contacts considered necessary for me to become a member, such as current employers, criminal records, etc. It is understood and agreed that any misrepresentation by me in this application, will be sufficient cause for cancellation of the application or for separation from MVRS as a member at any time. I understand that this application is the property of Mechanicsville Volunteer Rescue Squad, Inc. and will become part of my personnel file if I am accepted as a member. Driver record checks may be required in accordance with MVRS insurance carrier's requirements. I hereby authorize MVRS to obtain my complete driving history. POLICY STATEMENT: MVRS is an equal opportunity organization and shall not discriminate against any member or applicant due to age, sex, marital status, national origin, religion, race, physical or mental handicap unrelated to the performance of the job or any other prohibited reasons. The Membership Committee will review this application and additional information developed during background checks. Applicants may be disqualified for criminal conduct. If applicant is less than 18 years of age, a parent or legal guardian MUST submit this application.




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Mechanicsville Volunteer Rescue Squad, Inc.
28120 Old Flora Corner Road
P.O. Box 15
Mechanicsville, MD 20659
Emergency Dial 911
Non-Emergency: 301-884-2900
E-mail: info@co29.org
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