Membership Application
		Selma-Dallas County Rescue Squad, Inc. P.O. Box 766 Selma, AL 36702 Use The Print Function of Your Browser To Print Application. Mail Completed And Signed Application To Above Address.
	Date: _________________________                  Name: _____________________________________ Address: ___________________________________ Contact Phone Number:    (      )  _________ - ____________ Employment: ________________________________________ Occupation: _________________________________________ Hours of Work: ______________________________________ Can You Leave Your Place of Employment In Case of Emergency Call?    ___ Yes    ___ No Arrest Record:          Nature                               Location                                Date ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Training: Circle All That Apply. Swimming   Life Saving   First Aid   Radio Communication   FireFighting   Law Enforcment Medical   EMT   Paramedic   Boating   High Angle Rescue   High School Diploma College    Extraction   HAZMAT List Any Equipment, Personally Owned, That If Accepted Into Squad May Be Used By Squad With Out Fee or Obligation: ____________________________________________________________________________ ____________________________________________________________________________ NOTICE: YOU MUST HAVE COMPLETED AND HOLD A VALID FIRST-AID CARD BY THE END OF YOUR PROBATION PERIOD OR YOU WILL NOT BE ACCEPTED INTO THE SQUAD. ARE YOU WILLING TO TAKE A FIRST-AID COURSE? ___________ I, the undersigned, understand that the Selma-Dallas County Rescue Squad, is a volunteer organization to assist in the relief of emergencies or disasters that may occur in Selma, Dallas County or the surrounding counties, as needed. I hereby offer my services both in training and in mission at no cost to the county, Selma-Dallas County Rescue Squad, or person(s) assisted. Date: ___________________________ Signed: ______________________________  Print Name: _______________________________ If Under 18 Years of Age A Parent or Gaurdian Must Also Sign This Application. Members Under The Age of 18 Years Have Special Restrictions. I, _____________________________, Being Parent or Legal Gaurdian of Above Named Minor, Hereby Give My Consent For ____________________________, To Be Considered For Membership With The Selma-Dallas County Rescue Squad. Date: ___________________________ Signed: _______________________________  Print Name: _______________________________ Relationship To Applicant: ___________________________________