Name:______________________________________________________ Sex(  ) F (  ) M

Home Address:____________________________________________________________

City ___________________________________________ State:______   ZIP:__________

Phone:___________________________ E-mail Address:___________________________
 

College Address:___________________________Phone:___________________________
 

Email:_______________________________________SSN:________________________

Driver's License:

State:______ Number:__________________________

Issued:______________    Expires:________________

Circle Class Status: F  S  Jr  Sr  GradS          Major:_____________________________

AFFILIATION:  Do you presently belong, or have you belonged, to another EMS Squad?
  (    ) No   (   ) Yes.  If yes, how long?______

Do you now hold, or have you held an elected or appointed postion?
  (    ) No  (   ) Yes, if yes, what postition____________

EMS Units Name:_____________________________ Chief:_______________________

Address:____________________________________ Phone:_______________________

___________________________________________  State:______   ZIP:____________

TRAINING OR CERTIFICATIONS:  "X" below and indicate if you have current or past training and/or certification in the subjects listed:

(   )  NJ or NR Emergency Medical Technician  or -B   (    )  Paramedic  (   )  Nurse

       License or Certificate #:_____________________________

(   )  Other"________________________  What State:_______

       License or Certificate #:_____________________________

(   ) Red Cross Standard First Aid Red Cross Advanced First Aid

(   ) Cardiopulmonary resuscitation Defensive Driving

(   )  Red Cross, Level _______

(   )  American Heart ________

(   )  Other (explain)

________________________________________________________________

________________________________________________________________

References: Please provide the names, addresses and telephone numbers of three references. Do not use roommates or immediate family members.

1. Name:_________________________________ Phone________________________

Address:____________________________________ State:_______ ZIP:___________

2. Name:_________________________________ Phone________________________

Address:____________________________________ State:_______ ZIP:___________

3. Name:_________________________________ Phone________________________

Address:____________________________________ State:_______ ZIP:___________

RELEASE OF INFORMATION: I hereby authorize the University’s Department of Public Safety and the Executive Board of the Rowan University Squad to check these references and conduct a background investigation. I agree to hold harmless the State of New Jersey, University, the Emergency Squad, any official agencies or individuals and references for the release of information about me.  A copy of this application and signature should be considered as valid as an original.

Signature:_________________________________________ Date:___________________

Witness:__________________________________________ Date:___________________

College Address:____________________________________

A physical examination is required to join the squad. Upon conditional acceptance into the squad, you must obtain this examination through the student health center within 14 days.
 
 

FOR EXECUTIVE BOARD USE ONLY

Reference 1 checked? (   )  NO (   )  YES: (   )  Phone (   )  Mail     Date:____________

Reference 2 checked? (   )  NO (   )  YES: (   )  Phone (   )  Mail     Date:____________

Reference 3 checked? (   )  NO (   )  YES: (   )  Phone (   )  Mail     Date:____________

Interviewed By:_____________________________________ Date:_______________

Interviewer's notes:__________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Physical exam results received?    (   )  Yes, Date:_______ (   )  No

Driver's Investigation completed? (   )  Yes, Date:________ (   )  No

Additional Remarks:_______________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Membership (   )  Accepted/recommended (   )  Rejected,

Reason(s):______________________________________________________________

_______________________________________________________________________