New Member Packet
New Member Packet Instructions
The New Member Packet consists of the following documents:
- Volunteer Action & Change Form
- Consent to Release Results
- Volunteer Physical Options
- Volunteer Medical Interim Process
- Medical Clearance Summary
- Volunteer’s Copy
- LCFR’s Copy
- Testing for TB Infection
- VFIS Beneficiary Designation for Accident & Sickness Policy
- Length of Service Retirement Plan Beneficiary Designation Form
- VAVRS Form A Death Benefit Plan Application
Some of the documents are forms to be completed and submitted and some of the documents are informational only.
Instructions for completing the required forms:
1. Volunteer Action & Change Form
- New Member – A volunteer voted into the station whether new to the system or not. New volunteers can maintain dual membership
- Change – Used for demographic or station change. Membership will be transferred from one station to a new station. Former station affiliation will automatically be terminated. Enter New if volunteer wishes to maintain dual membership.
Complete questions 1 – 7.
Social Security – Enter the last four digits only of your social security number.
Company Name and # – Use Loudoun County Volunteer Rescue Squad #13
Volunteer’s Legal Name – Use full legal name. If a nickname is used include nickname surrounded by quote marks, i.e., “nickname”. The nickname can be used on the id if LCFR is notified that a nickname is preferred. For former name list any maiden names or legal name changes.
Mailing/Home Address – Provide a valid mailing address. PO Box addresses are acceptable. This is where benefit information will be mailed
Primary phone, secondary phone & email address
County – County in which volunteer resides
Date of Birth – please list as MM/DD/YYYY
Questions 8 – 13 are voluntary
Place of Employment & Occupation – Abbreviations are acceptable. This information is used for demographic trending
Male/Female – Check one button
Marital Status – Check one button
Race – Check all that apply
Ethnicity – Check one
I heard about volunteering with Fire-Rescue – Check all that apply.
Volunteer’s Signature and Date – Volunteer is also required to sign and date form that information provided is accurate to the best of his/her knowledge. Signature line follows Question 20.
Squad personnel will complete the remainder of the form.
2. Consent to Release Results
Print name and Company – Print your name and LCVRS13
Member’s Signature and Date – Sign and date that you acknowledge the information provided in the form and authorize consent to release information to company president. It is very important that you sign on the authorization line.
3. Medical Clearance Summary – LCFR’s Copy
Sign the three Volunteer Signature and Date Lines.
4. VFIS Beneficiary Designation for Accident & Sickness Policy –Name of Organization – Use LCVRS 13. Enter your name, date of birth and date voted into membership. Complete, sign and date beneficiary block if you wish to name or change your primary and/pr contingent beneficiaries.
5. Length of Service Retirement Plan Beneficiary Designation Form – Use blue or black ink. Provide all participant data. Complete all information for all primary and contingent beneficiaries you wish to name. This includes name, relationship to you, date of birth, social security number, and mailing address. The form must be signed before a notary or Loudoun County Government Benefit Staff member.
6. VAVRS Form A Death Benefit Plan Application
Complete Name, Social Security Number, Date of Birth and Address. For type of membership check Squad. For Squad/Organization use LCVRS 13. Add primary and Contingent Beneficiaries including relationship and address for each. Sign before a witness whose signature is also required. Squad personnel will complete the remainder of the form. The squad will pay the new member fee.
Once all the forms are completed submit them with your application. If you have any questions about the forms please contact the Membership Committee.
Membership Packet Documents for download:
Volunteer Action and Change Form
Consent to Release Results
Volunteer Physical Options
Volunteer Medical Interim Process
Medical Clearance Summary
Testing for TB Infection
VFIS Beneficiary Designation for Accident Sickness Policy
Length of Service Retirement Plan Beneficiary Designation Form
VAVRS Death Benefit Plan Application