Sterling Volunteer Rescue Squad

Volunteer Member Application Package

Thank you for your interest in volunteer membership with Sterling Rescue!

We are a progressive EMS agency with a focus on excellence in patient care. If you have a strong desire to help others, we may have an opportunity for you.

About Us:

The Sterling Volunteer Rescue Squad is an award winning emergency medical services agency with a diverse membership. We are a department of the Loudoun County Combined Fire-Rescue System and maintain a roster of approximately 180 volunteer members (both operational and administrative), providing EMS services to the community on a 24/7/365 basis. Our members are local residents, your neighbors, and others from throughout the Northern Virginia, DC, and Maryland. Regardless of their residence or background, our members are united as one team with a goal of delivering excellent care to our community.

In addition to emergency medical services, we provide technical rescue services including vehicle extrication, water rescue, and even an EMS Bike Team.

We take what we do very seriously, but we also want each member to have an enjoyable experience, so having fun in an atmosphere of mutual respect is an important part of our experience.

Membership Standards:

Candidates for membership must meet the following minimum standards:

·  Minimum age of 16.

·  Satisfactory driving record.

·  Satisfactory results from criminal background checks

·  Ability to function as an emergency medical technician including physical ability and ability to communicate in English, both orally and in writing.

New members must satisfactorily complete certain courses during their initial probationary period. The department pays for this training (if taken through a Loudoun County or department program):

·  Emergency Medical Technician (successful state certification)

·  Emergency Vehicle Operators Course

Membership Categories and Time Requirements

In order to ensure coverage of calls, members must commit to a category of membership based on their situation and availability. We accept for membership those candidates whose availability best meets our coverage needs. We are a “24/7/365” operation and must have coverage all day, every day of the year – including weekends and holidays. The Membership Officer will present specific scheduling options to each candidate based on the information they provide in the application. In general, all members must commit to a minimum of 12 hours per week. Those under the age of 18 or still in high school have greatly reduced duty requirements.

Getting Started:

Complete, sign and submit the Application for Membership, to include the following:

·  Completed and signed National Background Screening Form.

·  Copies of any EMS certifications, including CPR.

You may drop the completed packet off at the Cascades Fire-Rescue Station located at 46700 Middlefield Drive, Sterling, VA or email your completed application (preferred) to . You may also mail the packet to:

Sterling Rescue

Attn: Membership Officer

46700 Middlefield Drive

Sterling, VA 20165

The Membership Officer or a committee member will contact you to discuss the next steps.

If you have any questions, please contact us at:

** The application form below is a fillable form. PLEASE type your responses.

Sterling VOlunteer rescue Squad
Membership Application

Applicant Information

Last Name / First / M.I. / Date
Street Address / Apartment/Unit #
City / State / ZIP
Phone / E-mail Address
Date Available / Driver License Number / State / Date of Birth
Position Applied for
Are you a citizen of the United States? / YES / NO / If no, are you authorized to work in the U.S.? / YES / NO
Have you ever volunteered with a Fire/Rescue Company? / YES / NO / If so, when?
Have you ever been convicted of a felony? / YES / NO / If yes, explain

Education

High School / Address
From / To / Did you graduate? / YES / NO / Degree
College / Address
From / To / Did you graduate? / YES / NO / Degree
Other / Address
From / To / Did you graduate? / YES / NO / Degree

References

Please list three professional/personal references.
Full Name / Relationship
Company / Phone
Address
Full Name / Relationship
Company / Phone
Address
Full Name / Relationship
Company / Phone
Address

Employment

Company / Phone
Address / Supervisor
Job Title
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone
Address / Supervisor
Job Title
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO
Company / Phone
Address / Supervisor
Job Title
Responsibilities
From / To / Reason for Leaving
May we contact your previous supervisor for a reference? / YES / NO

Military Service

Branch / From / To
Rank at Discharge / Type of Discharge
If other than honorable, explain

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview
may result in my release.
Signature / Date

Duty Schedule

Based on your next six- to twelve-month schedule, please list the days and hours you ARE available for duty.

Use these hours as a guide:

Day Shift: 0600 to 1800 (6am to 6pm); Evening/Overnight Shift: 1800 to 0600 (6pm to 6am)

Sunday Day
0600-1800 / Sunday Night
1800-0600 / Monday
1800-0600 / Tuesday
1800-0600 / Wednesday
1800-0600 / Thursday
1800-0600 / Friday
1800-0600 / Day Crew
0600-1800 M-F

Please make your rank order choice of duty in the boxes above. Please choose your first, second, and third choices, based upon your availability. Please note that Day Crew is very flexible, with members being able to run any day of the week depending upon availability. Actual schedule will be discussed at the membership interview.

Every effort will be made to meet your requirements, however, crew assignments are based upon the needs of the Sterling Volunteer Rescue Squad.

CURRENT NREMT and/or VIRGINIA EMS CERTIFICATION

_____ None _____EMT _____EMT-E _____EMT-I _____EMT-P (Check highest level)

Certification Number: ______Expiration Date: ___/___/___

OTHER CERTIFICATION

Please indicate any additional related certifications:

____ EVOC

____ Extrication

____ Hazmat Awareness (or higher)

____ Swift Water Rescue ____Operations ___Technician

____ Rescue Diver

____ Public Safety Diver

____ Other: ______

BACKGROUND CHECK

Have you ever been convicted of any traffic or criminal offense in any state?

YES / NO -- If yes, provide details below.

** All applicants will undergo a thorough background check to include a national database search, fingerprinting and FBI data search. While a conviction will not necessarily disqualify an applicant for membership, failure to disclose will disqualify an applicant from further consideration**

APPLICANTS CERTIFICATION AND AGREEMENT

I certify that the information I have provided on this application is complete and accurate to the best of my knowledge. I hereby authorize the Sterling Volunteer Rescue Squad (SVRS) to verify the accuracy of this information. I authorize the SVRS to obtain reference information by contacting educational institutions, references, employers, other agencies and any other individuals or entities deemed necessary. I hereby release the SVRS and any of its representatives from any and all liability of whatever kind and nature which, at any time, could result from obtaining and having membership decision based on information obtained from this process. This application and all information obtained is the property of the SVRS. I understand that should an offer of membership be extended to me and accepted, I must fully adhere to the policies, rules and regulations of the SVRS and Loudoun County. I understand that membership is “at will” and may be terminated by the SVRS or by the member at any time, with or without cause.

I understand that if granted membership, falsified statements of any kind or omissions of facts called for on this application, regardless of the time of discovery, shall be considered sufficient basis for dismissal.

Applicant Signature: ______Date ___/___/___

Parent / Guardian Signature: ______Date ___/___/___

* If under 18 years of age

Authorization to Release Information

To Whom It May Concern:

I hereby authorize any authorized representative of the Sterling Park Volunteer Rescue Squad, Inc. bearing this release or a photocopy thereof, to obtain any information regarding my background from schools, agents, employers, criminal justice agencies (including the Virginia State Police as provided for in Section 19.2-389 of the Code of Virginia, as amended), or individuals. This information may include, but is not limited to the following: academic achievement reports, birth records, driver history/transcripts, and conviction/arrest records (including those found in the files of the Central Criminal Records Exchange). I hereby authorize and request your release of such information on request of the bearer. I understand that the information is for the official use of the Sterling Park Volunteer Rescue Squad, Inc. only as necessary for the fulfillment of their official activities. This authorization expires one-year of the date of signature of this document.

I hereby release the Sterling Park Volunteer Rescue Squad, Inc., the officers and directors of the Sterling Park Volunteer Rescue Squad, Inc., and any member of the Sterling Park Volunteer Rescue Squad, Inc. and/or any individual attempting to comply with this authorization of any and all liability for damages which may, at any time, result due to compliance or attempts to comply with this authorization. Should there be any questions regarding the authenticity of this release, you may contact me as indicated below.

______

Signature of Applicant

______

Date

Printed Name of Applicant ______

Address of Applicant ______

Other Name/Names ______

Social Security Number ______

Driver’s License Number ______Issuing State ______

Date of Birth ______City/State of Birth ______