Mechanicsville Volunteer Rescue Squad, Inc.
Mechanicsville Volunteer Rescue Squad

Interested in membership?
Fill out the following
Member Application.

January 169

2018 169
2017 2523
2016 2241
2015 2164
2014 1950
2013 2203
2012 2216
2011 2236
2010 2002
2009 2114

Today 573
Since March 9, 2009

Mechanicsville Volunteer Rescue Squad
Application for Membership
(This is not for access to the website)

Dear Applicant:

Attached is the application for membership in the MVRS, Inc. Please fill it out completely and provide any copies of certifications you may already hold (CPR, EMT, etc.).

The member health form is also attached and must be completed by you, signed by your physician and provided to our secretary prior to you being turned over to ride the ambulance. Please also fill out and sign the consent form for the criminal background check.

For clarification purposes:

An Active Member is someone who is or wants to be an EMT or higher and who has turned 18 years old.

A Driver-Only Member is someone who is at least 21 years old and who wishes to only join as a driver (CPR required).

A Provisional member is a person who is at least 16 and wishes to become an EMT but has not yet turned 18; or who is an Emergency Medical Responder (EMR).

An Administrative Member is one who does not wish to drive or become certified as an EMS provider and will only perform administrative duties as assigned. These members do not ride on the ambulance.

The other membership types are self-explanatory.

Once you have turned in your application our President and the Chief will meet with you to introduce themselves and tell you about our department.

Our Business Meetings are held on the 3rd Wednesday of every month at 7PM. Your application will be presented to membership at the next business meeting after you have completed the above. Please plan to attend the meeting. After that meeting you will be given an Orientation presentation to familiarize you with our building, apparatus, by-laws and Standard Operating Guidelines.

We are so pleased that you have chosen to apply for membership in our department and look forward to getting to know you.

All information submitted is subject to verification. A false statement may
result in disqualification for membership either now or at a later date.
Type of Application: New Reinstatement from Inactive Membership

Check Membership Applying for:
Cadet(age 14 & 15)
Active(age 18 & up with EMT-B Certification or Higher)
Driver only (age 21 & up)(age 21 & up)
Administrative (age16 & up)(age16 & up)
Provisional (age 16 & 17 with 1st Responder or higher; or age 18 or higher with EMR)
Associate(current member at another rescue/fire dept. in Tri-County with EMR or higher)
Personal Information:
Name (First) (Middle)(Last)
Date of Birth
Telephone (Work) (Home) (Cell)
Email Address
Marital Status:Single Married Widowed Divorced
Drivers License
Do you have a Driver's License? Yes No

Number:State Issued:
Have you ever been convicted or posted collateral/bail for any traffic violation? Yes No
If yes, list all such offenses with date, place, and action taken.
Emergency Information: Who can we contact for you in case of an emergency?
Background Information: A signed Volunteer Employment 'Consent/Release Form' by St. Mary's County Volunteer Emergency Services is required when this application is received and tabled at the meeting.
Have you ever been convicted of a misdemeanor or felony or are you under charge(s) for a misdemeanor or felony? Yes No
If yes, list all offenses and state date, place and action taken:
Current Level of Training: Please submit copies of any certifications you hold for any EMS/Fire Training and course work completed including dates of completion and/or expiration.
Training LevelMFRI / MIEMSS I.D. NumberCompleted or Expiration Date
Additional Rescue Squad / EMS / ALS / Fire Information:
Are you a member of another Rescue Squad, EMS, ALS or Fire Department? Yes No

Have you ever been a member of another Rescue Squad, EMS, ALS or Fire Department? Yes No

Has your service in any Rescue Squad, EMS, ALS or Fire Department organization been terminated for any reason other than retirement or VOLUNTARY resignation? Yes No

If yes, explain:
List all Rescue Squad, EMS, ALS or Fire Department organizations to which you were either a paid and/or volunteer member.
Organizations From To Offices Held
Are you currently employed? Yes No

Place of Employment:
Please read Carefully
By submitting this application for membership in the Mechanicsville Volunteer Rescue Squad, Inc. (MVRS), I authorize investigation of all statements contained therein. I hereby authorize MVRS to make any contacts considered necessary for me to become a member, such as current employers, criminal records, etc. It is understood and agreed that any misrepresentation by me in this application, will be sufficient cause for cancellation of the application or for separation from MVRS as a member at any time.

I understand that this application is the property of Mechanicsville Volunteer Rescue Squad, Inc. and will become part of my personnel file if I am accepted as a member. Driver record checks may be required in accordance with MVRS insurance carrier's requirements. I hereby authorize MVRS to obtain my complete driving history.

POLICY STATEMENT: MVRS is an equal opportunity organization and shall not discriminate against any member or applicant due to age, sex, marital status, national origin, religion, race, physical or mental handicap unrelated to the performance of the job or any other prohibited reasons. The Membership Committee will review this application and additional information developed during background checks. Applicants may be disqualified for criminal conduct.

If applicant is less than 18 years of age, a parent or legal guardian MUST submit this application.
Type 'Certify' if you agree.

Mechanicsville Volunteer Rescue Squad, Inc.

28120 Old Flora Corner Road
P.O. Box 15
Mechanicsville, MD 20659
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