Fredericksburg Volunteer Rescue Squad
Fredericksburg Volunteer Rescue Squad

Calls in the beginning
1940 28
1976 4,400
1940-1977 69'000

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Since
November 15, 2012
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Visitors Today
Apr 27, 2024
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Membership Application

The Fredericksburg Rescue Squad, Inc. does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, gender, marital status, national origin, disability or handicap, veteran status or any other protected status. 

Required   Indicates Required Field
Personal Data
Name:
Last, First Middle 		Required
Nick Name:
Street Address: Required
City: Required
State: Required
ZIP Code: Required
Primary Telephone Number: Required
Secondary Telephone Number:
Email Address: Required
Date of Birth: Required
Social Security#:
This is for the background check. 		Required
Why do you want to join Fredericskburg Rescue: Required
How did you learn about Fredericksburg Rescue: Required Internet Search
From a current member
Newspaper Ad
Word of mouth
Mobile Advertisement
Other
Emergency Contact/Disclosure Contact
Emergency Contact Name: Required
Emergency Contact Relation: Required
Emergency Contact Telephone Number: Required
Alternate Contact Telephone: Required
Certifications
Current Certification: Required None
EMT-B
EMT-E
EMT-I
EMT-P
Expiration Date:
Certification #:
Has your Certification/License ever been investigated, suspended, or revoked?: Required No
Yes
CPR Expiration:
EVOC Expiration:
Driver's License #:
If you do not have a Drivers' License, enter N/A. 		Required
License State:
Have you ever been charged with Traffic Violation, Reckless Driving, Criminal Misdemeanor, or Felony?:
Have you ever been charged with Traffic Violation, Reckless Driving, Criminal Misdemeanor, or Felony? If yes, an email will be sent to you for more information. If you answer yes, it will not necessarily exclude you from consideration. 		Required No
Yes
FEMA Courses: ICS-100
ICS-200
ICS-300
ICS-400
ICS-700
ICS-800
High School
High School Years Completed: Required 1
2
3
4
HS Certificate: Required None
Diploma
GED
School::
School City, State, Zip:
University/Vocational School
University/Vocational School Years Completed:: 1
2
3
4
Degrees Earned:
University/Vocational School Name:
University/Vocational School City, State, Zip:
Previous Volunteer Organization
Previous Volunteer Organization From Date:
Previous Volunteer Organization to Date:
Still Associated: Yes
Department Name:
Department Address:
Supervisor/Chief Officer:
Supervisor/Chief Officer Number:
Previous Volunteer Organization Duties:
Reason for Leaving Previous Volunteer Organization:
Have you ever applied or been a member with Fredericksburg Rescue Squad?: Required No
Yes
How Did You Hear About Us?: Required
Employment
Dates of employment From:
Dates of employment to:
Company Name:
Company Address:
Street Address, City, State, Zip
Company Phone Number:
Employer Phone Number:
Supervisor’s Address:
Street Address, City, State, Zip
Supervisor’s Email:
Supervisor’s Phone Number:
Reason for leaving:
List a full description of any disciplinary actions against you with date:
References
Personal Reference #1:
Name, Phone, Address, Relation 		Required
Personal Reference #2:
Name, Phone, Address, Relation 		Required
EMS Reference #1:
Name, Phone, Address, Relation
EMS Reference #2:
Name, Phone, Address, Relation
Electronic Signature
Typed Signature:
AUTHORIZATION FOR RELEASE OF PERSONAL INFORMATION I hereby authorize the view of and full disclosure of all records or any part thereof concerning myself, by and to any duly authorized agent of the Fredericksburg Rescue Squad, whether the said records are of a public, private or confidential nature. This authorization intends to give my consent for full and complete disclosure of all records- wherever located, which pertain to me. This authorization overrides any claim of privilege or confidentiality previously made by me or on my behalf. This authorization covers but is not limited to the following, which is by way of illustration and not by way of limitation: • Criminal records of complaint, arrest, trial, and/or convictions for alleged or actual violations of law, including criminal and traffic records (except records which a court has expunged); • Civil records of complaints of a civil nature made by or against me, wherever located (including records and recollections of attorneys-at-law or other counsel, whether representing another person or me in any case in which I presently have or had an interest). This authorization intends to provide full and unrestricted access to the background and history of my personal life for the specific purpose of pursuing a background investigation that may provide pertinent data for the Fredericksburg Rescue Squad to consider in determining my suitability for membership. The purpose of such research is to assess my character and personality as they pertain to my ability to perform the duties of the position to which I have applied. My specific intent is to provide access to personal information, however personal or confidential it may appear to be and the sources of information specifically listed above are not intended to deny access to any records not explicitly identified herein. I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this Release Authorization will be considered in determining my suitability for membership with the Fredericksburg Rescue Squad and I fully understand that a refusal to grant this authorization will not; of itself; constitute a basis for rejection of my application. 		Required
Date Application Submitted: Required 04/27/2024 0922
Administration Portion (to be completed by admin)
Applicant Withdrew:

Your signature above certifies that the information contained in this application is true and correct to the best of your knowledge.

Your signature above authorizes the view of and full disclosure of all records or any part thereof concerning myself, by and to any duly authorized agent of the Fredericksburg Rescue Squad, whether the said records are of a public, private or confidential nature.

This authorization intends to give my consent for full and complete disclosure of all records- wherever located, which pertain to me. This authorization overrides any claim of privilege or confidentiality previously made by me or on my behalf.  This authorization covers but is not limited to the following, which is by way of illustration and not by way of limitation:

  • Criminal records of complaint, arrest, trial, and/or convictions for alleged or actual violations of law, including criminal and traffic records (except records which a court has expunged);
  • Civil records of complaints of a civil nature made by or against me, wherever located (including records and recollections of attorneys-at-law or other counsel, whether representing another person or me in any case in which I presently have or had an interest).

This authorization intends to provide full and unrestricted access to the background and history of my personal life for the specific purpose of pursuing a background investigation that may provide pertinent data for the Fredericksburg Rescue Squad to consider in determining my suitability for membership. The purpose of such research is to assess my character and personality as they pertain to my ability to perform the duties of the position to which I have applied.

My specific intent is to provide access to personal information, however personal or confidential it may appear to be and the sources of information specifically listed above are not intended to deny access to any records not explicitly identified herein.

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this Release Authorization will be considered in determining my suitability for membership with the Fredericksburg Rescue Squad and I fully understand that a refusal to grant this authorization will not; of itself; constitute a basis for rejection of my application.

You understand any misrepresentation, falsification, or material omission on this application may result in rejection of your application, disciplinary action to include expulsion and prosecution by the Fredericksburg Rescue Squad.

I further understand and will comply with the rules and regulations as set forth in the Constitution and By-laws of the Fredericksburg Rescue Squad.




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 Fredericksburg Rescue Squad
510 William Street
Fredericksburg, VA 22401

 Emergency Dial 911
Non-Emergency: 540-373-3264
Fax: 540-373-0480
E-mail: info@fxbgrescue.org
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