OnLine Application

Dear Prospective Member,

Thank you for expressing interest in joining the Loudoun County Volunteer Rescue Squad (LCVRS). This Page contains the forms and instructions necessary to get you started.

For the first phase of the application process:

  1. Complete the Online Application for Membership below and submit the application. You will receive a copy of your submitted application by email. You will also be contacted by a member of our membership committee by email to provide you with additional information about the second phase of the process.
  2. Download and complete the following forms:
    • Driver Information Request Form – Fill in the “Subject’s Personal Information” and “Subject’s Driving Information” sections of the DMV Information Request. Be sure to include your driver’s license number and sign and date the Driver’s Authorization. Do NOT fill in the top section entitled “Requestor Information.” Include a photo copy of a current driver’s license. If you do not have a driver’s license, please include a copy of a current learner’s permit, DMV issued identification card, or other official government issued identification.
    • Criminal History Record Form – Complete Section 3 only (Name to be Searched section). Your signature is NOT required on this form.
    • Ride Along Agreement Form – This is an optional form. If you wish to participate in a ride-along during the application process, complete the Ride-Along Agreement.

Return the completed forms and photo identification to our rescue station located at 143 Catoctin Circle SE Leesburg or mail to:

LCVRS
Attn: Membership Committee
PO Box 1178
Leesburg, VA 20177

If you have any questions, please call us at 703-777-7185, email us at membershipcommittee@lcvrs.org, or visit our website at www.loudounrescue.org.

General Information Questions

Type of Membership: (Membership Classifications)

Membership Status: (LCVRS Staffing Explanation)

First Name: (required)

Middle Name:

Last Name: (required)

Maiden Name:

Other Names ever used:

Street Address: (required)

City: (required)

State: (required) Zip: (required)

Primary Phone: (required)

Secondary Phone:

Your Email: (required)

Gender: (required)

Age: (required)

Birthday: (mm/dd/yyyy) (required)


Employer or School Questions

Employer/School:

Employer/School Address:

Emergency Contact Name:

Emergency Contact Number:


General Health Questions

Do you have any health problems or physical limitations?
 Yes No

If yes, please explain:

Please check any medical history that applies:
 Heart Respiratory Ulcers Nerve/Psychological Allergies Back Problems

Loudoun County requires you to pass a physical to be covered under the heart/lung bill and the county’s worker’s compensation plan. The physical is provided free of charge. Will you agree to this?
 Yes No


License Information

Please provide the following information about your driver's license:

List Endorsements (i.e., CDL):

List Restrictions:

List moving violations within the last 5 years:

Have you ever been convicted of, or are you currently charged with, violations of laws other than traffic violations?
 Yes No

If yes, please explain:


Rescue Related Questions

Please indicate your first choice for which shift you would like to run:

Please indicate your second choice for which shift you would like to run:

Please indicate your third choice for which shift you would like to run:

Why do you want to become a member of the Rescue Squad?

Do you have any special skills or knowledge that may benefit the Rescue Squad?
 Yes No

If Yes:

What languages do you speak and at what level of fluency?

List any fire or rescue certification that you hold. Include Certification Level, Expiration Date, Name of Instructor, and Location of Training:

List any fire or rescue instructor certification that you hold. Include Certification Level, Expiration Date, Name of Instructor, and Location of Training:


Background Related Questions

Are you currently chemically dependent on any illegal substances?
 Yes No

Have you ever used, tried, or experimented with any unlawful drugs or controlled substance in any form? (Just once means you should answer YES.
 Yes No

If YES to question above, have you used an illegal substance within the last 5 years?

If you are currently a member of another Rescue Squad or Fire Department, list the name, address and phone number of that squad/dept.

If you have ever been a member of another Rescue Squad or Fire Department, list the name, address and phone number of that squad/dept.

Personal Reference
(At least one must be current employer, teacher or
principal. All must be someone other than family members.)

Name:

Relationship:

Phone: Years Known:

Name:

Relationship:

Phone: Years Known:

Name:

Relationship:

Phone: Years Known:


The Loudoun County Volunteer Rescue Squad does not discriminate against gender, age, race, religion or national origin. The information provided on this application is for identification and volunteer processing purposes only. All information will remain confidential within the Loudoun County Volunteer Rescue Squad. If any information is found to be falsified, it shall be cause for immediate dismissal from the rescue squad. Your application can also be rejected due to the criminal history record check, DMV license check, Inova Occupation physical results and reference calls.

I do hereby give the Loudoun County Volunteer Rescue Squad permission to obtain and verify the information provided on this application. If I am selected for membership, I will abide by the Loudoun County Volunteer Rescue Squad’s constitution, policies and procedures.