Join Us

Please fill out the information below if you would like to start the process of volunteering or working with us. Paid employment requires current certification as an EMT or higher.

Membership/Employment Inquiry

Name *

First

Middle

Last

Name You Go By

Date of Birth

Current Occupation

Permanent Address *

Mailing Address

Home Phone *

Cell Phone

Email *

Are you interested in volunteering or paid employment? *

Are you currently certified as an EMS provider in Virginia? *

EMS Certification Level

Virginia EMS Certification Number

Current/Previous EMS Agency Affliation

Please provide the name, address and phone number of the agency (or agencies).

Previous Employment

Please list all previous employers and include your job title along with the address and phone number of the business.

Personal References

Please list three (3) personal references along with their contact information.

Have you ever applied for employment with the rescue squad before?

If yes, when

Have you ever been convicted of any criminal offense?

If yes, give offense and dates

List any Emergency Medical or Rescue Training you have received

Please send copies of certificates to [email protected].

Minimum Age Requirement *

I understand that the minimum age to work or volunteer at the Prince Edward Volunteer Rescue Squad is 16 years of age.

Signature Declaration *

I declare that the above information is true and complete to the best of my knowledge. I authorize the Executive Committee to review criminal background checks and motor vehicle reports for use during the application process. I understand that if any part of this application is found to be false, my application will be rejected and I will not be considered again for membership to this organization. I also agree, upon acceptance into the membership, to abide by the Constitution and By-Laws and Standing Operating Procedures and to obtain all training needed to remain a member in good standing.

Signature of Applicant *

Date *

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