Application For Membership

Thank you for taking the first step in joining a growing organization of dedicated healthcare professionals. Please fill out the following form, and a squad representative will contact you shortly.

If you have questions about your application, contact the recruitment committee at


Personal Information
First Name
Middle Name
Last Name
E-mail Address:
  NOTE: Rutgers students may wish to supply a non-Rutgers e-mail address. Rutgers spam filters seem to be fairly overzealous.
Home Phone Work Phone Cell Phone  
Date of Birth (Month/DD/YYYY)  
/ /  
Height Weight
Eye Color Hair Color
Marital Status: Single Married Divorced Separated
# of Dependents
Drivers License Number Expiration (mm/dd/yyyy)
/ /

Employment & References
Occupation Work Schedule
Days Evenings Nights Shifts
Employer Name Employer Phone
Employer Address:
List the Name, Address, and Phone of Two References

Previous Experience
Did you belong to a First Aid or Rescue Squad previously?
Yes No     If yes, which one?
Please verify if you have any of the following certifications
First Aid
CPR (Professional Rescuer)
Exp. Date
Exp. Date
Exp. Date

Personal History & Questionnaire
Are you currently a US citizen? Yes No
    If no, what country are you from?
History of Back Ailments? Yes No
History of any other Chronic Illness? Yes No
Ever been arrested for a crime?
(Other than a traffic offense)
Yes No
Use Recreational Drugs / Narcotics? Yes No
Objection to Police Records Check? Yes No

Legal Agreement
I understand and agree to the above statements.
I understand and agree to the above statement.
If you have concerns about data security, you may enter only as much information as you like. The only mandatory fields are First Name, Last Name, E-Mail address, and the two checkboxes at the bottom. In this case, you will be asked to fill out a paper application instead.


The East Brunswick Rescue Squad is a non-profit organization that does NOT collect taxes, we heavily depend on donations and the return we get from our annual fund drive.

We now provide you with a secure online place to submit donations by using your Visa, MasterCard, Discover, or American Express credit card. You can also mail your check or money order to the address found here.

As we are a 501(c)(3) organization, all donations are tax deductible to the fullest extent of the law.
We thank you in advance for your donation.

Click here to learn more about donating to EBRS.