Volunteer Application Form - SCC-EMS - Sun City Center Emergency Squad

Name *

Nickname *

Primary Phone: *

Secondary:

Email *

Address *

City *

Zip *

Date of Birth *

Social Security Number: *

Gender: *

Male

Female

Race: *

Emergency Contact: *

Phone: *

Preference for Volunteer Service: *

Do you reside in the area full-time? *

Yes

No

Months you reside in area *

Previous Occupation(s) *

Have you previously applied to or volunteered at the Squad? *

State(s) of residence in last five years: *

Have you ever been arrested/convicted of a crime? *

Have you ever been convicted of a felony? *

Do you have any physical limitations or medical problems which would impact your participation on the Squad? If so, what type? *

I give permission to you to check my driving record and to do a background check. I attest that I do not use any illegal drug and that I will at no time perform Squad duties after consuming alcohol or any substance (including medications) that might lessen my ability to respond appropriately. *

Yes

No