Volunteer Membership Application - Wintergreen Rescue Squad / Wintergreen Fire Department
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3WINTERGREEN RESCUE SQUAD / WINTERGREEN FIRE DEPARTMENT
Volunteer Membership Application
We welcome your interest in our organization. The Chief (434-325-8536) of the Wintergreen Rescue Squad and/or
Wintergreen Fire Department will review your application and may invite you attend an interview. We conduct a
criminal history investigation and review the Department of Motor Vehicle (DMV) Driver Transcript for all new
applicants. This form includes an authorization for us to conduct and/or review these documents. If your
application is approved you will become a probationary member for a period of not less than (6) six months.
Rescue Squad (
Full,
Junior) and/or
Fire Department
Check all that apply
Name: _______________________________________
Date: _____ / ______ / ___________
Address: ______________________________________________________________________
______________________________________________________________________________
Telephone:
Home: _____ - ______ - ___________ Work: _____ - ______ - ____________
Cell:
_____ - ______ - ___________
Email: _______________________________________________________________________
Date of Birth: ____ / ____ / _________ Height: ______________ Weight: _____________
Education: _______________________ Highest grade completed: ______________________
In case of emergency, notify: Name: ________________________________________________
Relationship: _________________________________________________________________
Telephone:
Home: _____ - ______ - ___________
Work: _____ - ______ - ___________
Cell: _____ - ______ - ___________
Do you agree to volunteer a minimum of 36 hours as a “Full” or “Junior” member, (Rescue
Squad only)? Yes or No
Circle One
Are you now or have you ever been affiliated with a police, fire or rescue organization?
Yes or No
Circle One
If yes, provide details: ___________________________________________________________
______________________________________________________________________________
May we request your performance record from that organization? Yes or No
Circle One
Have you ever been convicted of a law or traffic violation? Yes or No
Circle One
If yes, list all and please explain: __________________________________________________
______________________________________________________________________________
Do you have any infirmity or medical condition that would impair your ability to perform any of
the duties customarily required of a volunteer member of the Rescue Squad or Fire Department?
If yes, please explain: ___________________________________________________________
______________________________________________________________________________
Note: This includes vision, night driving, or mobility issues.
Updated March 11, 2016
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