Fremont Rescue and EMS, Inc.
Junior Membership Application
Name  
 Middle Name
 Last Name:  
Street Address:  
 City
 Zip Code
Home Phone  
 Cell Phone No.  
 Work Phone
Parent or guardian (if
applicable)
 Same Address?
Address:  
 City
 Zip Code
Home Phone  
 Cell Phone No.  
 Work Phone
Age  
 Date of birth
 Social Security Number
School You Attend
(if applicable)
 Grade
Are you employed?   
 If so, place of employment
Do you have any special training or skills that you could contribute to the Jr. Squad?  If yes, describe.  
Are you able to lift 60 pounds?  
 Are you able to attend training
at least once a week?
Have you ever been convicted of a crime?  Misdemeanor or Felony?
(including traffic offenses)   
If yes, explain
Please list 3 references (Do not include family)
NAME                                        ADDRESS                          PHONE NUMBER
(I state that the above information is true to the best of my knowledge).  I understand that falsifying
information or giving untrue statements is grounds for my application to be rejected or grounds for
dismissal from the Jr. Program.   
Signature (Electronic):      
Date