First Aid Fund Drive

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Amount:
$215,000
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$205,000
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95%
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01/01/2012

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Freehold First Aid & Emergency Squad, Inc.

VOLUNTEERS SERVING FREEHOLD BOROUGH AND FREEHOLD TOWNSHIP SINCE 1941

18 SPRING STREET – FREEHOLD, NEW JERSEY 07728

APPLICATION FOR MEMBERSHIP

 

Thank you for your interest in joining Freehold First Aid and for using our quick online application. This application process takes approximately three minutes and is the correct form to use for all membership types; including Cadet and Auxiliary. Additional information about our application process can be found in our FAQ Section.

 

RELEASE OF INFORMATION

By completing this Online Membership Application belonging to Freehold First aid & Emergency Squad, Inc., you solemnly and truthful pledge:

To all courts, probation departments, police departments, officers and judges in charge of expungement records, schools, colleges, physicians, psychiatrist, psychologists, mental health clinics, hospitals, medical records centers or bureaus, collection agencies, credit reporting bureaus or agencies, selective service boards, military services, military records bureaus and centers, unemployment and disability offices, insurance companies, workmen compensation companies and courts, and any and all other institutions, agencies, persons, businesses without exception:

THAT the person submitting this application is the same as the person named and identified

AND THAT said person is making an application to the Freehold First Aid and Emergency Squad, Inc.

AND THAT as a result an investigation is being conducted to determine said person’s eligibility.

AND THAT said person hereby authorizes to release, without liability onto you, or your company, agency, bureau or institution, and an all information, records, documents, reports, evaluations, examinations, or any all other information pertaining to me that they may request.

A photocopy, facsimile or computer print of this authorization will be deemed as effective and valid as the original.

 

Freehold First Aid Online Application Form
First Name * Required - Please provide your given name
Last Name * Required
Street Address * Physical Address Required

No PO Boxes
Apartment/Suite
City * Required - Even if it is not Freehold
State * Required - Hopefully this is New Jersey
Primary Phone * Required - The best number to reach you

Type only numbers, no dashes or spaces
Alternate Phone
Zip Code * Required - Even if it is not 07728
EMail * Recommended - EMail address you regularly review. If none, we recommend you obtain one to be a user of the website.
Date of Birth * Required
Prior Member How many years, if any, have you spent as an active Emergency or Medical Responder?
Squad/s of Prior Membership If yes to prior experience, please name the organization/s you served.
Reason/s for Leaving If yes to prior experience and organization/s, please describe reason/s for leaving
Years as Licensed Driver If a licensed driver, how many years have you been driving?
Current Employer If employed please list your current employer
Years with Current Employer If employed please provide number of years at current employer
Referral Type * Important - How did you learn of Freehold First Aid?
Referral Detail Please share more detail how you learned of FFAS
Digital Signature Freehold EMS may begin a review of your application immediately. To authorize use of your application information, according to the terms of the application, even before a formal interview, please type I CONSENT to allow a faster application.
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