Emergency Services of Barron County
Volunteer Membership Application
Last Name *
Your answer
First Name *
Your answer
Middle Initial *
Your answer
Home Mailing Address *
Your answer
Home Physical Address *
Your answer
Date of Birth *
This information will be used to pull your driving record (as required by state law)
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/
DD
/
YYYY
Drivers License Number *
This information will be used to pull your driving record (as required by state law)
Your answer
Email Address *
Your answer
Do you want to sign-up for the countywide first responder email group? *
This email group will be used to share information on upcoming training, location hazards, announcements, etc.
Cell Phone Number
This number will be used for "I Am Responding" call notification
Your answer
Cell Phone Provider
(AT&T, Verizon, etc) This will be used for "I Am Responding" call notification
Your answer
Are you a United States citizen? *
Can you provide legal proof of eligibility to work in the Unites States?
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