Please note that the purpose of this form is to gather basic information about you to send to the recruiting personnel at the Rescue Squad. This form is not an application for membership with the Rescue Squad.
An application will be extended after eligibility is verified.

Indicates Required Field

Full Name:
Street Address:
City:
State:
Zip Code:
Contact Phone:
E-Mail Address:
Preferred contact method:		E-Mail Phone
Are you currently CPR certified at the Health Care Provider Level:		No Yes
Are you a currently licensed EMT in the State of Alabama:		No yes
If you a currently licensed EMT in the State of Alabama, at which Level:		No EMT-P AEMT EMT-B
Aside from Health Care Provider Level BCLS (CPR)/EMT what credentials do you hold that will help you at the Rescue Squad:
What prompted you to take interest in the rescue squad? What is your reason for wanting to join:
Who (if anyone) were you referred by: