First
Name:
Last Name:
Address:
City:
State:
Zip Code:
Date of Birth :
(mm/dd/ccyy format)
Home or Cell Phone Telephone:
E-Mail:
If you do not live, work or go
to school in Wayne, please tell us why
you would like to be a volunteer for our
community.
Experience, skills, Training and Certifications
(EMT, CPR, First Aid, NIMS, ICS, etc)
Please list type and expiration date:
What is the best time to reach you to arrange
an interview?:
Wayne
First Aid adheres to the Americans with
Disabilities Act of 1990. Individuals
who qualify and require reasonable accommodations
for a disability, please check the box
below for us to make special arrangements.
A description of your disability and diagnostic
or evaluative materials provided
by an appropriate certified or licensed
professional which is dated within 3 years
of the date of your request for accommodations
will be required. Wayne First Aid reserves
the right to determine the reasonability
of the request and alternative accommodations.
Check the box here to request reasonable
accommodations.
Only check if you
qualify for the Americans with Disabilities
Act of 1990.
ALL
STATEMENTS OF FACT MADE HEREIN ARE CORRECT
TO THE BEST OF MY KNOWLEDGE. IF I AM ACCEPTED
AS A MEMBER OF THE WAYNE MEMORIAL FIRST
AID SQUAD, I PROMISE TO CONDUCT MYSELF IN
ACCORDANCE WITH THE RULES AND PURPOSES OF
THE SQUAD AND TO CONDUCT MYSELF IN A PROFESSIONAL
MANOR WHEN ENGAGED IN TREATING THE PUBLIC.