Arapahoe Rescue Patrol New Member Application Applicant's Name: * First Middle Last Current Address Applicant's Address: * City: * Zip Code: * Mailing Address Enter only if different than home address. Mailing Address: City: Zip Code: Contact Information Applicant's Cell Phone Number: * Cell Phone Service Provider: * — Select — AT&T Wireless Verizon T-Mobile Sprint PCS or Sprint Nexel Virgin Mobile USA Bell Mobility Bell MTS Boost Mobile Cellular One Fido / Microcell FirstNet Illinois Valley Cellular Koodo Mobile Mobilfone Rogers Sasktel Telus Mobility Tracfone US Cellular Unicel Other This information is key to making sure you can receive mission pages correctly. If you select other, you will be contacted for more information. Applicant's Non-School Email Address: * Please enter an email you will check regularly. This email will be used for application updates, your required background check, as well as dispatch paging. Do not use a school email address. Applicant's Home Phone Number: Applicant's Other Phone Number: Applicant Information Date of Birth: * Age: * Sex: * — Select — Female Male Other Height: * Weight: * Hair: * — Select — Black Brown Blonde Gray / White Other Eyes: * — Select — Amber Blue Brown Gray Green Hazel Red Other Driver's License Number: If Applicable Driver's License Expiration: If Applicable Preferred Name Tag Name: * What name you would like printed on your required name tag Education School you currently attend: * Current Grade: * — Select — 8 9 10 11 Other School you will attend next fall: * Grade next fall: * — Select — 9 10 11 12 Other Current Grade Point Average: * Year you will graduate High School: * Employment Please fill out the following section only if you answered yes below. Do you currently have a job: * — Select — Yes No Business Name: Position: Supervisor's Name: Phone Number: Will you be able to get off work for a mission: — Select — Yes No Parent / Legal Guardian Information You must fill out information for at least 1 parent / legal guardian. Parent / Legal Guardian 1: Name: * First Last Relationship: * Address: * City: * Zip Code: * Mailing Address: If Different Preferred Phone Number: * Preferred Email Address: * Parent / Legal Guardian 2: Name: First Last Relationship: Address: City: Zip Code: Mailing Address: If Different Preferred Phone Number: Preferred Email Address: Parent / Legal Guardian 3: Name: First Last Relationship: Address: City: Zip Code: Mailing Address: If Different Preferred Phone Number: Preferred Email Address: Parent / Legal Guardian 4: Name: First Last Relationship: Address: City: Zip Code: Mailing Address: If Different Preferred Phone Number: Preferred Email Address: References List at least one teacher, one school administrator, and one person in the community as references. You may list one other in addition to these three if you wish. Make sure those listed are aware that you are using them as a reference. Reference 1: Name: * First Last Phone Number: * Position: * Reference 2: Name: * First Last Phone Number: * Position: * Reference 3: Name: * First Last Phone Number: * Position: * Reference 4 - (Optional) Name: First Last Phone Number: Position: Experience Please list any backcountry experience that you have had (hiking, camping, scouts, etc.) as well as any special skills or special training that might be applicable (first aid, scuba, rock climbing, etc.): * Explain your reasons for wanting to join the Arapahoe Rescue Patrol, Inc. Include what you have to offer to the team and what you seek to gain from your membership: * Recent photo of yourself: Select Image Image of your school transcript: Select Image Emergency Contact Information The following information is confidential and will only be accessible to those affiliated with the Arapahoe Rescue Patrol, Inc. with a demonstrated need to know or to other emergency services personnel in the event the member is injured or otherwise unable to provide the necessary information. This information will not be reviewed by the application review board and any information provided will not be considered in the application. In the event a member is accepted, the following information will be securely stored and only accessed in the event of a member emergency. In the event of a medical emergency during an Arapahoe Rescue Patrol activity, emergency care will be provided in accordance with Colorado law and Denver Metropolitan Emergency Medical Services protocols, including implied consent for minors. All reasonable attempts will be made to contact those listed on this form if circumstances allow. Mother's Information Mother's Name * First Last Mother's Address * City * Primary Phone * State * Secondary Phone Zip Code * Cell Phone Mother's Email Address * Father's Information Father's Name * First Last Father's Address * City * Primary Phone * State * Secondary Phone Zip Code * Cell Phone Father's Email Address * Other Emergency Contact's Information Name * First Last Address * City * Primary Phone * State * Secondary Phone Zip Code * Cell Phone Email Address * Medical Information Doctor's Name * Doctor's Phone * Allergies * Medications * Medical History * Do you have a history of tuberculosis, or have you ever come in contact with someone with active tuberculosis? * — Select — Yes No Please check the corresponding box for each of the following vaccines that you have recieved. MMR (Measles / Mump / Rubella) DTP / DtaP (Diptheria / Tetanus / Pertussis) OPV / IVP (Polio) HBV (Hepatitis B 3 Series Immunization) Varicella (Chickenpox) Meningococcal Meningitis Membership Agreement and Parental Approval Have you done anything in the past, or is there anything in your background that, if you are accepted, may discredit the Patrol? Yes/No: * — Select — Yes No If “Yes”, please write an explanation: “I hereby agree that, if I am selected for membership in the Arapahoe Rescue Patrol, Inc. I will take all the required training courses, secure the necessary equipment, and participate in all required trainings and all regular missions unless specifically excused. I agree to respect and follow the instructions of the Patrol Officers and the Rules and Regulations governing the Patrol. I also understand that upon submission of this application, I must complete a criminal background check through the provided link at the end of this application and that any information provided on this application will be subject to verification. I understand that my electronic signature below is the legal equivalent of my handwritten signature.” Applicant Signature: * To the Applicant: Show this application to your parent/legal guardian. Have them read it carefully and discuss it with them. If they approve of your participation in the Arapahoe Rescue Patrol, Inc. have them sign below. Only one signature is required, however, both signatures should be affixed if possible. “I (We) understand that the Arapahoe Rescue Patrol, Inc. is an equal opportunity organization and I (we) have been informed that the Arapahoe Rescue Patrol, Inc. provides no adult chaperones on its activities. I (we) also understand that upon submission of this application, our son/daughter will complete a criminal background check through the link provided at the end of this application to verify their identity and any information provided on this application. I understand that my electronic signature below is the legal equivalent of my handwritten signature.” Signature: * Relationship: * Signature: Relationship:
