Application for Membership to the Pennington First Aid Squad

Name Birth Date

Address

Email address

Social Security Number Phone number(s)

Driver's License Number + state Optional:    Male Female

Current Medical Certifications (attach copies of current cards)

CPR         First Responder        EMT(B,other)      First Aid
Emergency vehicle operations        Other health care provider

Have you ever been convicted of a crime?        Yes         No If yes, give details

Have you been vaccinated for Hepatitis B?        Yes         No If yes, please attach proof to application.

After training, you must be able to fulfill the job description of an EMT. Are there any physical or mental reasons why you might be unable to perform patient care as an EMT? Examples might be lifting, squatting, kneeling, hearing, vision.
Yes         No If yes, give details.

Please give us three references we can call. References must not be relatives.

Name Phone

Name Phone

Name Phone

I have read the job description attachment and I attest that I have no physical or mental limitations that would prevent me from performing patient care as an EMT with or without a reasonable accommodation. I agree to obey all Pennington First Aid Squad regulations and return all Squad property when I leave the Squad.

Signature

Date