HVRS New Member Application

Do you have a valid driver's license? *

State *

License Number *

Expiration Date

Please list any pending moving violations that may not appear on your driving record at this time.

Do you have any health problems or physical limitations? (Detail YES answers below) *

Are you presently under a physician's care? (Detail YES answers below) *

Are you currently taking any medications? (Detail YES answers below) *

Do you have any of the following (Check all that apply, detail answers below)

Heart problemsRespiratory problemsUlcersDisabilitiesNerve problemsPsychological problemsAddictionsAllergies

Please detail all YES answers are checked boxes in the below section:

Hamilton Volunteer Rescue Squad