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2. Date*
   Date
4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
15. What is your occupation?*
    If you are a student please indicate your school and current grade level.
16. Current employer?
17. Are you less than 18 years old?*

    1. Yes
    2. No
19. Are you interested in becoming a:
    -- Select One --EMTAdvanced EMTI already hold a VT EMS license
20. If you already have an EMS license, what level?*
    -- Select One --EMREMTAEMTParamedicI'm a physician, RN, PA, veterinarianI do not currently have an EMS license
22. Do you have any relevant medical or EMS experience?
    Please describe any relevant licences, training, education, or experience. If you have none, tell us about your work history and what skills you would bring to EMS.
24. Availability
    Members are expected to run a regular, full, 12-hour shift each week and at least one 12-hour weekend shift each month. Weekend shifts are scheduled for a volunteers convenience. Day shift begins at 0600h (6:00 am) and end at 1800h (6:00 pm). Night shift begins at 1800h (6:00 pm) and ends at 0600h (6:00 am). Please indicate your availability to volunteer during the week.
26. Day Time Availability

    1. Sunday
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
    6. Friday
    7. Saturday
27. Night Time Availability

    1. Sunday
    2. Monday
    3. Tuesday
    4. Wednesday
    5. Thursday
    6. Friday
    7. Saturday
29. Essay*
    Please explain your interest in Milton Rescue. If you are new to Emergency Medical Services, explain what drew you to this opportunity. Also, please explain a previous volunteer or employment experience that might contribute to our squad strength and diversity.
31. References
    Please provide the name, occupation, and contact information (phone and/or email) for at least two professional references. Family members may not serve as references.
33. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
35. Electronic Signature
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field