EMS Volunteer Application

DOUGLAS-OKANOGAN COUNTY FIRE DIST. #15
VOLUNTEER APPLICATION
EMS
PLEASE PRINT
NAME: _____________________________________________________________________________
MAILING ADDRESS _______________________________________________________________
PHYSICAL ADDRESS _____________________________________________________________
CITY: _________________________________ STATE: ______________ ZIP: ________________
PHONE NUMBER(S)_______________________________________________________________
SSN _________-_____-_________ DRIVERS LICENSE _________________________________
ARE YOU 18 YEARS OF AGE OR OLDER? YES NO
EMERGENCY CONTACT: NAME: ________________________ PHONE: ________________
ARE YOU CURRENTLY EMPLOYED? YES NO
WHO IS YOUR EMPLOYER? ______________________________________________________
MAY WE CONTACT YOUR EMPLOYER? YES NO
EMPLOYER PHONE NUMBER: ____________________________________________________
ARE YOU ELIGIBLE FOR EMPLOYMENT IN THE UNITED STATES? YES NO
(PROOF OF CITIZENSHIP OR IMMIGRATION STATUS WILL BE REQUIRED UPON EMPLOYMENT).
HAVE YOU BEEN CONVICTED OF A FELONY OR MISDEAMEANOR OTHER
THAN MINOR TRAFFIC VIOLATIONS IN THE LAST 7 YEARS?
(CONVICTION WILL NOT NECESSARILY DISQUALIFY AN APPLICANT). YES NO
IF YES, PLEASE EXPLAIN:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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EDUCATION
DO YOU POSSESS A HIGH SCHOOL DIPLOMA OR GED? YES NO
HIGH SCHOOL: ____________________________________ YEAR GRADUATED: _________
COLLEGE/TRADE SCHOOL: ________________________GRADUATE? YES NO
MAJOR/AREA OF STUDY: _________________________________________________________
OTHER PERTINENT TRAINING AND/OR SKILLS:
_____________________________________________________________________________________
_____________________________________________________________________________________
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CURRENT HEALTH CARE PROVIDER CPR CARD? YES NO
ARE ALL OF YOUR IMMUNIZATIONS CURRENT? YES NO
ARE YOU CURRENTLY, OR HAVE YOU IN THE PAST, BEEN TREATED FOR A
MEDICAL CONDITION THAT MAY LIMIT YOUR ABILITY TO PERFORM THE
DUTIES THAT ARE REQUIRED OF YOU? YES NO
IF YES, PLEASE EXPLAIN:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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PLEASE PROVIDE FOUR REFERENCES, OTHER THAN FAMILY MEMBERS, AND
WHO DO NOT RESIDE WITH YOU.
NAME: _______________________________________ PHONE:____________________________
NAME: _______________________________________ PHONE:____________________________
NAME: _______________________________________ PHONE:____________________________
NAME: _______________________________________ PHONE:____________________________
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WAIVER AND HOLD HARMLESS AGREEMENT FOR REFERENCE AND
BACKGROUND CHECK:
I ___________________________ AUTHORIZE THE DISCLOSURE OF PAST
EMPLOYMENT INFORMATION REGARDING MY CHARACTER, ABILITY TO
LEARN, RELIABILITY, DEPENDABILITY AND HONESTY. I RELEASE BOTH THE
PROSPECTIVE AND PREVIOUS EMPLOYERS FROM ALL CLAIMS AND
LIABILITES ARISING FROM THE RELEASE OF SUCH INFORMATION. IN
ADDITION, I AUTHORIZE DOUGLAS-OKANOGAN COUNTY FIRE DISTRICT #15
TO CONDUCT A CRIMINAL BACKGROUND CHECK, OBTAIN A DRIVING
ABSTRACT, AND I AGREE TO A PHYSICAL EXAMINATION AND AGREE TO BE
DRUG TESTED AT THE EXPENSE OF DOUGLAS-OKANOGAN COUNTY FIRE
DISTRICT #15S DISCRETION. I AGREE TO FUNCTION WITHIN DOUGLAS-
OKANOGAN COUNTY FIRE DISTRICT #15S POLICIES, PROTOCOLS, AND
WASHINGTON STATE LAW.
THIS MUST BE SIGNED AS A CONDITION OF ACTIVE ASSOCIATION WITH
DOUGLAS OKANOGAN COUNTY FIRE DISTRICT #15.
APPLICANTS SIGNATURE ____________________________________ DATE: ____________
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