Volunteer

Reference Two

Reference Three

The reading and signing of this statement acknowledges that all the information contained in my volunteer membership application is true and accurate to the best of my knowledge.

I understand that any willful falsification of information listed herein will mean that my membership will be immediately revoked.

I also hereby give my permission to Western Berks Ambulance Association to submit the information listed to the Pennsylvania State Police, or other appropriate Police Department(s), for a criminal record check to be conducted on myself.

I understand that I must submit a check or money order for the amount of $25, payable to Western Berks Ambulance, with this application to cover processing costs.

It is further understood that if I refuse to sign this statement acknowledging the aforementioned, my application will not be considered.

If applicant is under 18 years of age, parent or guardian signature is required above and below.

I understand that the above mentioned applicant will be involved in the delivery of Emergency Medical Services with Western Berks Ambulance Association and said applicant has my permission to do so.