HVRS HVRS Application Online Membership ApplicationSelect type of membership applying for: Regular Adult (Runs Fire & EMS Calls, MAY run Heavy Rescue and Water Rescue)Regular Junior (Under 18, Runs Fire & EMS Calls)Administrative (Does NOT run Fire and EMS Calls)Special Operations (Runs Heavy Rescue, Water Rescue Calls Only, MAY run Fire/EMS Calls) Personal InformationName * Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry Phone * Email * Gender *MaleFemale Date Of Birth * Current Certifications *None ListedHealthcare Provider CPRCommunity CPRVirginia EVOC-1Virginia EVOC-2Virginia EVOC-3EMT/EMT-BEMT-EEMT-AEMT-IEMT-PFirefighter 1Firefighter 2Swift Water RescueLPNRNPAMD Please list other certifications or qualifications you would like us to know about Place Of Employment (Including Address and Phone Number) * Reference 1, With Contact Information * Reference 2, With Contact Information * Background InformationDo you have a valid driver's license? *YesNo State * License Number * Expiration Date Please list any pending moving violations that may not appear on your driving record at this time. Do you have any health problems or physical limitations? (Detail YES answers below) *YesNo Are you presently under a physician's care? (Detail YES answers below) *YesNo Are you currently taking any medications? (Detail YES answers below) *YesNo Do you have any of the following (Check all that apply, detail answers below) Heart problemsRespiratory problemsUlcersDisabilitiesNerve problemsPsychological problemsAddictionsAllergies Please detail all YES answers are checked boxes in the below section: Availability / Interests / SkillsDo you presently work: *Shift WorkDaysNightsWeekendsI Don't Work Do you now, or have you ever been a member of any other fire or rescue department *(If more than one, select your most recent, or primary, company)No1 - Leesburg Volunteer Fire2 - Purcellville Volunteer Fire3 - Middleburg Volunteer Fire/Rescue4 - Round Hill Volunteer Fire/Rescue5 - Hamilton Volunteer Fire6 - Ashburn Volunteer Fire/Rescue7 - Aldie Volunteer Fire/Rescue8 - Philomont Volunteer Fire9 - Arcola Volunteer Fire/Rescue10 - Lucketts Volunteer Fire/Rescue11 - Sterling Volunteer Fire12 - Lovettsville Volunteer Fire/Rescue13 - Loudoun Volunteer Rescue14 - Purcellville Volunteer Rescue15 - Sterling Volunteer Rescue16 - Neerseville Volunteer Fire/Rescue17 - Hamilton Volunteer RescueLoudoun County Fire Rescue (Career Staff)Fairfax County Fire/Rescue (Career Staff)Other Department What skills are you bringing to Hamilton Rescue? What activities are you willing to assist with? Emergency Calls - EMSEmergency Calls - Heavy RescueEmergency Calls - Water RescueMeetingsRoutine TransportsTrainingStand By EventsFund DriveAdministrativeWork DetailsPublic EducationRecruiting Hamilton Rescue staffs our trucks in 12 hour shifts. Members are generally required to run one 12 hour shift a week, and a rotating schedule on weekends, based on demand and staffing. Which of the following shifts are you currently available to run duty? *WeekdaysMonday 6pm - Tuesday 6amTuesday 6pm - Wednesday 6amWednesday 6pm - Thursday 6amThursday 6pm - Friday 6amFriday 6pm - Saturday 6amSaturday 6am - Saturday 6pmSaturday 6pm - Sunday 6amSunday 6am - Sunday 6pmSunday 6pm - Monday 6amNon EMS MembershipNone of the above Why do you want to join HVRS? * If selected for membership, I will abide by the Bylaws, Policies and Standard Operating Procedures of the Hamilton Volunteer Rescue Squad and Loudoun County (type name to indicate your agreement) * HVRS does not discriminate based on age, race, sex, religion, marital status or national origin. The information gathered is for identification and job assignment purposes only. Type your name to indicate your understanding * HVRS reserves the right to verify all information on this application. Type your name to indicate your understanding. * VerificationPlease enter any two numbers (Example: 12) *This box is for spam protection - please leave it blank