Application For Membership

Thank you for taking the first step in joining a growing organization of dedicated healthcare professionals. Please click the link below to download our PDF application. You must save it to your computer and open it with Adobe Reader or another PDF program. You can fill it out and save it on your computer, and submit it via email as an attachment.

Important: The "click to submit" button will open your email program and send the application as an attachment. This won't work from your browser. If the button doesn't work, save the completed PDF on your computer, attach it to a new email, and send it to the email address below.

Please allow 10 days for an email reply. If you do not receive one, please contact us to make sure your application was received.

Please click for our application.

If you have questions about your application, contact us at

Do not use the application below. It will not be submitted to EBRS, and will not be processed.


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 Cell Phone
Date of Birth (Month/DD/YYYY)  
/ /  
Height Weight
Eye Color Hair Color
Social Security Number (Not required for application.)
Drivers License Number
Expiration (mm/dd/yyyy) / /

Emergency Contact
Who should we contact in case of emergency?
Phone Numbers:

Certifications & Previous Experience
Please verify if you have any of the following certifications:
First Aid
CPR (Professional Rescuer)
Exp. Date
Exp. Date
Exp. Date
What is your NJ EMT number?
What other relevant certifications do you hold?
Describe any previous experience in EMS:
Copies of your certifications will be requested upon receipt of your application.

List the name, relationship, phone number, and email address of three professional references (i.e. not just friends, but people who are familiar with your professional, volunteer, or school experience and accomplishments.)
We will contact your references only after your in-person interview. We strongly prefer to have email addresses to contact your references. Your references' contact information is used only in relation to your application and no other purpose whatsoever.

Occupation & Student Status
What is your occupation?
Employer's Name:
Employer's Phone Number:
Employer Address:
If you are a student, what institution do you attend?

Health & Medical Information
Do you have a history of back ailments? Yes No
Do you have any type of heart condition or ailment? Yes No
Do you have any type of breathing problems? Yes No
Do you have any history of any other chronic illness? Yes No
Do you have any problems that prevent you from lifting up to 75 lbs? Yes No
Do you have any condition that could affect your service, or that you feel we should be aware of? Yes No
If you answered "Yes" to any of the above, please explain. Please also list any accommodations you require.

Referral to EBRS
Please tell us how you heard about EBRS, if you know any current or former members, and if you have any family involved in emergency services.

Background Information
Do you use narcotics, recreational drugs, or any other restricted or illegal substances? Yes No
Have you ever been arrested or charged with a crime (other than minor traffic violations)? Yes No
Do you object to a police background / record check? Yes No
If you answered "Yes" to any of the above, please explain.
Are you eligible to work in the United States? Yes No

I affirm that all of the above information is true and correct to the best of my knowledge, and I understand that false statements or representations on this form or during the application process are cause for immediate dismissal from the East Brunswick Rescue Squad (EBRS).
If accepted, I agree to abide by all EBRS Bylaws, Policies, and Procedures that are in force at any given time. All EBRS property issued to me must be surrendered upon separation or dismissal.
I understand that to be eligible for membership, I must maintain current certifications in compliance with EBRS policies, as well as state and federal requirements for emergency responders.
Regular Membership (18+) Applicants Only: If accepted, I agree to: provide sufficient availability to fulfill a minimum requirement of four 12-hour shifts each month; and attend the membership meeting on the second Tuesday of each month and the training class on the fourth Tuesday of each month, or arrange absences in advance.
Cadet (under-18) Applicants Only: I agree that I will fulfill the minimum requirement of 12 hours of service each month and attend the training class on the fourth Tuesday of each month. I understand that my participation in EBRS is subject to the approval of my parent or legal guardian. I agree that upon the later of my 18th birthday or high school graduation, I will be subject to the requirements of Regular Membership with EBRS.
I affirm that I have read and agree to the statements above.
I agree that typing my full name below serves as my electronic signature.
Type your full name here:
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.

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.