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Demographics

First Name

Last Name

Email

Phone

Address Line 1

Address Line 2

City

State

Postal Code

Preferred contact method

Are you a US Citizen?

Date of Birth

Preferred Name (if different)

Valid Driver's License?

License Number

State of Issue

Gender

Membership

How did you find out about Blacksburg Rescue?

Are you a year-round resident of Montgomery County?

How long do you plan to live in the area?

BVRS offers several categories of memberships to allow flexibility for members with other full-time commitments.

Please read the expectations for each membership category and indicate your choice below (If you aren't sure yet, make your best guess. This can be adjusted later once you speak with our team).

General Expectations:

Participate in squad activities and present a positive image of the squad.
Assist or participate in special projects, standbys, community events, training, meetings, etc.
Complete and maintain any required training and certifications based on your membership category.
Voting members are expected to attend all monthly business meetings when able.
Pass a background check and meet other minimum standards as required by OEMS.

Training Requirements:
You do NOT have to be trained when you join. Necessary training will be provided!

Junior Members (those age 16-18) - CPR & First Aid
Emergency Medical Service (EMS) Providers - Virginia EMT, AEMT, EMT-I, or Paramedic, CPR
Drivers - must be age 20 or older (per our insurance), EVOC, good driving record, in-house training
Technical Rescue - First Aid, CPR, certification and/or in-house training (varies depending on discipline)

Membership Categories:

Full Membership
*We recommend this category for most EMS members starting out to ensure their success through the initial onboarding and training process.

40 hours/month
For EMS providers, 16 of those hours must be on a recurring duty group

Associate Membership
*It can be difficult for some EMS members to complete their initial training at this commitment level. Members are welcome to participate in both EMS and Technical Rescue but when you first apply at this level, you will be asked to specify your initial focus (EMS or Technical Rescue).

Associate EMS - 20 hours/month, 16 of those hours must be on a recurring duty group
Associate Technical Rescue - 20 hours/month
Junior (for those age 16-18) - 20 hours/month

Support Membership
*Aside from Administrative (non-operational) roles, we RARELY bring on new members in this category. It is primarily intended for established members who, due to changes in life circumstances or availability, need need to reduce their level of commitment but wish to remain actively involved with the squad.

Administrative - 10 hours/month, non-operational, must provide a needed administrative service as determined by squad leadership
Technical Rescue - 10 hours/month
Special - 10 hours/month, current members who meet specific criteria may temporarily move to this category
Medical Director - Physician and operational medical director for our agency. Expectations are outlined in a contract with that physician.

Expected Availability

Please describe your availability. What days/times would you be available to help?

Education

Highschool

High school you attended?

Highest grade completed?

Did you graduate?

GED?

Post-Secondary

College/University

School Name

Location

Degree/Certificate

Major

School Name

Location

Degree/Certificate

Major

School Name

Location

Degree/Certificate

Major

Other Education

School Name

Location

Major

Please describe the Certification or Specialty

Employment History

Are you legally eligible for work in the U.S.?

Have you ever been fired or asked to resign from a job?

If yes, please explain

Please list your last three (3) places of employment, beginning with the most current.

Employer 1

Employer Name/Position

Start Date

End Date

Supervisor Name

Phone

May we contact?

Current

Current Employer

Employer 2

Employer Name/Position

Start Date

End Date

Supervisor Name

Phone

May we contact?

Current

Current Employer

Employer 3

Employer Name/Position

Start Date

End Date

Supervisor Name

Phone

May we contact?

Current

Current Employer

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Statement of Comittment

Statement of Commitment

1. If accepted, I agree to abide by all federal, state, and local laws, the constitution, and the bylaws of BVRS, the agency’s standard operating procedures, and other rules of the agency.

2. I can be asked to resign or be dismissed from membership from BVRS based on failure to follow the above-mentioned laws and guidelines.

3. Membership commitment is requested for a minimum of two years. Longer term commitment may be required in situations where specific training is required.

4. If accepted, I must possess and maintain valid, current, CPR and first aid/EMS certification, with a copy of the current cards on file with BVRS.

5. If accepted without a current EMT certification, I must enroll in a certification class within six months of acceptance (unless I am applying as a Technical Rescue member).

6. If accepted, I must keep all certifications under which I want to practice current. This includes EVOC if I wish to be a driver and any technical rescue (extrication, search and rescue, etc.) certifications should I wish to participate in such activities.

7. If accepted I agree, as a condition of membership, to check my squad email (blacksburgrescue.org), update my contact information upon any change, and notify personnel as well as the applicable deputy chief of a leave of absence.

8. I give BVRS permission to pull and check my DMV driving record at any point during my membership with the agency. Out-of-state personnel will be required to obtain this from their state DMV.

9. I agree to be contacted via the contact information I provided in the “Demographics” section of this application and agree to update this information as necessary.

10. I agree to notify BVRS within 10 days of any criminal convictions and/or traffic charges incurred through the duration of my membership.

11. All information stated in this application is complete and correct to the best of my knowledge. I understand that any misinformation found may be grounds for dismissal from the agency.

I have read, understand, and agree to the above and hereby apply for membership with the Blacksburg Volunteer Rescue Squad (BVRS)

References

Please provide name and contact information for 3 references

Reference 1

First Name

Last Name

Phone

Email

Reference 2

First Name

Last Name

Phone

Email

Reference 3

First Name

Last Name

Phone

Email

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Criminal and Background Information

Have you ever been convicted of any offense against the law? Please omit any juvenile offenses and/or minor traffic violations. Please include conviction by general court martial while in the military service. Please note, checking yes does not automatically mean that you cannot become a member. The nature and date of the conviction are important. Please provide all of the facts so that a decision may be made

If yes, please give date, place, chart, court, and fine/sentence

Criminal Record Acknowledgement

Please read carefully:

Pursuant to § 32.1-111.5, each person who, on or after July 1, 2013, applies to be a volunteer with or employee of an emergency medical services (EMS) agency must submit fingerprints and provide personal descriptive information to be forwarded by the Office of EMS (Office) along with his fingerprints through the Central Criminal Records Exchange (CCRE) of the Virginia State Police to the Federal Bureau of Investigation, for the purpose of conducting a state and national criminal history check.

The Blacksburg Volunteer Rescue Squad has adopted the Virginia disqualifying factors as outlined in 12VAC5-31-910 as disqualification from membership or affiliation eligibility.

Please read the following statement and sign and date the form in the appropriate locations. Falsification of this information may be considered sufficient cause for rejection.

I affirm that I have never been convicted of a felony involving any sexual crime or other disqualifying offence as outlined in 12VAC5-31-910. I understand that I must disclose to the Chief any arrest or pending charges that, if convicted, would disqualify me for membership as above. I understand that by signing this form, I authorize Blacksburg Volunteer Rescue Squad to obtain my criminal or any other background information.

I have read, understand, and accept the above statement

Vehicle Extrication	Search and Rescue	Technical Rescue Dispatch	Vertical Rescue
Cave Rescue	Trench Rescue	Structural Collapse	Swiftwater Rescue
Confined Space	Dive Recovery

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