PLEASE PRINT THIS FORM AND RETURN TO THE WATCHUNG RESCUE SQUAD.

Any requests for cadet membership will be put onto our Cadet Waiting List

WATCHUNG RESCUE SQUAD

Application for Membership

Release and Consent

If accepted as a member of the Watchung Rescue Squad, I agree to abide by all rules and regulations set forth by the squad. I further agree that I will not divulge confidential information pertaining to squad calls, patient information, personnel, or business affairs of the squad.

I affirm that I do not have any illness, physical, or mental disorders that would prevent me from performing the assigned rescue squad duties. If requested, I will supply the names of any treating doctors, hospitals, or other medical facilities for medical conditions listed above. I will also consent to any random physical examination after age of 55, at the expense of the squad.

I certify that all the information on this application is true, that all pertinent information regarding driving privileges, criminal offenses, and medical information may be obtained by the squad and that a copy of this application may act as a release authorization form. Copies of any records will be retained by the squad and will be kept confidential. All original records will be returned after review by the Chairperson of the Membership Committee.

Full Name:

I accept the above statement

Parental Consent for Cadet Members

I hereby consent to allow my son/daughter to participate as a cadet member of the Watchung Rescue Squad.

Full Name:

I accept the above statement


Date:
Membership Type:	Active Driver Cadet Affiliate Other
First Name		Middle Initial
Last Name
Street Address
City
State
Zip
Home Phone
Pager/Cell
E-mail
Date of Birth
Age
SS#
DL #
Sex	Male Female
Spouse	Emg. Contact Name:
Emg Phone
Employer:
Occupation
Emp Address
Emp City
Emp State
Emp Zip
Work Phone
Please answer the following questions, If YES explain under remarks:
1. Have you ever been a member of another emergency service organization? Yes No
2. Has your driver's license ever been suspended in this or any other state? Yes No
3. Have you ever been convicted of a felony within the last 7 years? Yes No
4. Do you have medical limitations which may prevent you from performing squad duties? Yes No
Remarks:
Do you have any of the following certifications:
1. Cardio-Pulmonary Resuscitation (CPR) Yes No Expires:
2. Basic First Aid / First Responder Yes No Expires:
3. Emergency Medical Technician (EMT) Yes No Expires:
4. Hazardous Materials Yes No Expires:
Other Certs:
Active • Driver • Cadet Applicants		All Applicants
What days and hours are you available for calls?		What committee(s) would you like to serve on?
Monday	Day Night	Finance
Tuesday	Day Night	Buildings & Grounds
Wednesday	Day Night	Fund Raising
Thursday	Day Night	Social
Friday	Day Night	Historical
Saturday	Day Night	Publicity
Sunday	Day Night	Membership
Please provide two references (Not related to you):
Personal Evaluation forms will be sent to those listed below. The application process will continue upon their return:
1. Name:
Street:
Zip:
Phone:

2. Name:
Street:
Zip:
Phone: