APPLICATION FOR MEMBERSHIP

REVA VOLUNTEER FIRE & RESCUE

Instructions: Please print or type all information.  Answer all questions in full.

Please print this form and either mail or hand carry to the address listed on the contacts page.

Date of Application______________________________

I would like to apply for: Fire Active_____EMS Active_____Active Support_______Jr. Membership____________________

Name: _________________________________________________________________________________________________

             (Last)                                                          (First)                                                    (Middle)

Address: ________________________________________________________________________________________________

                  Street                                                                   City                       State                        Zip                                                      

I can be reached at: ________________________________________________________________________________________________________

       (Home phone)                         (Work phone)                     (Cell Phone)                 (Pager)                     (E-Mail Address)

Date of Birth_______________________ Age____________ Martial Status: __________________________________________

Employer: ______________________________________________________ Occupation: _______________________________

How far from Reva Volunteer Fire & Rescue do you live?: __________________________________________________________

Please tell us your reason(s) for wanting to become a member of Reva Volunteer Fire &Rescue. ____________________________ _________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Are you currently a member of a Fire and or Rescue Company, and if so please tell us which one? __________________________ 

__________________________________________________________________________________________________________

Have you ever been affiliated with any Fire/Rescue Company?  If so, please tell us which one(s) and your reason(s) for leaving. __________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Please circle or fill in the correct answer.

Have you been convicted of a felony in the past?  Yes   No

Will you be willing to submit to a criminal background check?   Yes    No        SSN______________________________________

Do you have a valid driver’s license? Yes    No    State Issued: _______________ License Number: __________________________

I will provide a driving record to become a driver for Reva Volunteer Fire & Rescue.  Yes   No

List the names and phone numbers of three people (not relatives) that we may contact as references.  List their relationship to you.

1. ___________________________________________________________________________________________________
2. ___________________________________________________________________________________________________
3. ___________________________________________________________________________________________________

TRAINING

Please mark the following with an (X) if you currently have the training or with an (O) if you are willing to obtain training.

Firefighter Training:  Firefighter I___ II___III___ Fire Instructor I___II___III___ Fire Officer I___II___III___CPR___ EVOC___Hazmat___ Arson Investigator___ Other (Specify) _______________________________________________

EMS Training:  First Aid___ First Responder___ EMT-B___ EMT-Enhanced____ EMT-ST____ EMT-CT ____

EMT-I____EMT-Paramedic___ EVOC___ CPR____ Other (Specify) ___________________________________

Supporting Members: I would like to help with: Fundraising_____Dinners_______BINGO_____Administration_____Other: (Specify skills or type of support you have to offer_____________________________________________________

(OVER)

MEDICAL HISTORY

Have you had a physical in the past year (12 months)?  Yes   No

If yes give approximate date and name of physician_________________________________________________________________

Please tell us if you have any of the following by placing a (Y) for Yes or (N) for No beside the question.

Heart problems____ Asthma____ Physical Deformities____ Seizures____ Rheumatic Fever____ Swelling of the legs or ankles___

Fractured Bones____Dislocated Joints____ Wear glasses or contacts____ Lung Problems____ Back Injuries____ Dizzy Spells____

Severe Headaches____ Operations____ Overweight (50+ lbs) _____ been refused life insurance____ any physical or mental problems not listed here_______________________________________________________________________________________

Please explain any yes answers_________________________________________________________________________________

__________________________________________________________________________________________________________

Height: ________ Weight___________                          Do you smoke?  Yes   No  

Do you consume alcoholic beverages?   Yes   No           Please define your drinking class:  Seldom____ Social____ Often____

I agree to a post accident health screening__________________________________________________________ (Your Signature)

 List the name, relationship and phone number(s) of the person(s) you would want us to contact in case of emergency.

1. _________________________________________________________________________________________________
2. _________________________________________________________________________________________________

I have read the above statements, and to the best of my knowledge, declare them as being true and correct.  I hereby authorize Reva Volunteer Fire and Rescue to verify my employment records and moral character with whomever it is deemed to have this knowledge.  If elected into membership of this company, upon my honor, I pledge to obey the orders of the President, Chief, Captain, Lieutenant, or any other officer, executive or line, or any senior member placed in command.

Signature: ______________________________________________________________________________

If under 18, parent’s signature required______________________________________________________

FOR COMPANY USE ONLY