Membership Application

Reference 1 - Name / Phone Number / Relationship *

Do you have your own transportation? *

Yes

No

Phone *

THE CHESTERFIELD RESCUE SQUAD DOES NOT DISCRIMINATE ON THE BASIS OF RACE, SEX, OR RELIGION. THE CHESTERFIELD RESCUE SQUAD DOES REQUIRE THAT YOU RESIDE WITHIN THE COVERAGE AREA. THE SQUAD ALSO REQUIRES THAT WITHIN ONE YEAR OF BECOMING A MEMBER OF THE CHESTERFIELD RESCUE SQUAD YOU ARE EITHER CERTIFIED AS AN ASHI CERTIFIED EMERGENCY MEDICAL RESPONDER OR IN AN ASHI EMERGENCY MEDICAL RESPONDER CLASS, BUT EVERYONE IS ENCOURAGED TO GET THEIR NR-EMT. *

Yes (I understand)

No (I do not understand)

Do you have any special training? *

Reference 2 - Name / Phone Number / Relationship *

Email *

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Current Occupation *

Social Security Number

Name: *

Driver's License Number / State *

I UNDERSTAND THAT I WILL BE CONTACT BY THE CAPTAIN OR HIS/HER DESIGNEE TO SET UP MY APPEARENCE INFRONT OF THE SQUAD TO BE VOTED ON. THIS CONTACT MAY BE THROUGH EMAIL AND/OR TEXT MESSAGE TO MY PHONE NUMBER/EMAIL PROVIDED. FAILURE TO REPLY WILL RESULT IN MY APPLICAION NOT BEING BROUGH BEFORE THE SQUAD. *

Yes (I understand)

No (I do not understand)

Date of Birth *

Address *

What do you expect to gain from the rescue squad? *

Current Working Hours. *

Reference 3 - Name / Phone Number / Relationship *

THE RESCUE SQUAD HAS 2 MEETINGS A MONTH AN IST (INSERVICE TRAINING) MEETING ON THE TUESDAY IN THE SECOND FULL WEEK OF THE MONTH AND A BUSINESS MEETING ON THE 4TH MONDAY OF THE MONTH. MEMBERSHIP APPLICAITONS WILL BE VOTED ON DURING OUR NORMAL BUSINESS MEETINGS. *

Yes (I understand)

No (I do not understand)

Can you swim? *

Yes

No

A little