Application for Probationary Membership
Name:
Date of Birth:
Address:
,
email Address:
Home phone number:
Cell phone number:
Emergency Contact:
Contact No:
Drivers License No.
Automobile Insurance Provider:
Medical conditions or allergies:
Special Training or Skills:
Current certifications: (list CPR, EMT no’s or other relevant certifications)
How did you hear about Bluegrass Search and Rescue?
Reference #1- (must be current or prev. employer)
Name:
Title:
Phone:
How long did you work for this person?
Reference #2:
Phone:
How long have you known this person?
Reference #3:
Phone:
How long have you known this person?
Do you have medical insurance?
Yes
No
Can you swim?
Yes
No
Have you ever been convicted of a felony?
Yes
No
Have you ever been convicted of a misdemeanor?
Yes
No
If yes, please explain:
Please provide dates & details for any traffic violations within the past 5 years:
I certify the above information is correct and provide permission for the three listed references to be contacted by a representative of Bluegrass Search and Rescue.
Signature (by filling in, denotes legal signature)
Date
For Internal Use Only:
Date Application submitted: ____________
First meeting attended: _____________
Date Accepted on Probationary Status: __________