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APPLICATION FOR MEMBERSHIP Columbia County Dive Rescue and Recovery Team 3910 Desoto Dr. Martinez, GA 30907 Phone: (706) 863-7745 Fax: (706) 863-7015 General Information and Instructions You must be 18 years of age to apply for the Columbia County Dive Rescue and Recovery Team. Evaluations of applications are based on individual merit. Information MUST BE COMPLETE so that all applications can be given equitable consideration. All qualified applicants will receive consideration for membership regardless of race, color, religion, sex, age, national origin or disability. Columbia County Dive Rescue and Recovery Team will accept for membership only authorized workers, regardless of national origin. There are five forms that MUST be completed in this document: 1) The Columbia County Rescue and Recovery Team Application; 2) the Hold Harmless Agreement; 3) the Medical Statement; 4) the Motor Vehicle Report form; and 5) the Criminal History Consent form (background check). All of these forms may be completed online, printed out, signed, and submitted to the Columbia County Fire Rescue office at 3910 Desoto Drive, Martinez, GA 30907. When submitting your application, you must provide a state issued photo ID or Military photo ID. You must sign and date your application in ink. Signature fields are highlighted in yellow, and you may not type in those fields; you must sign those fields in ink after printing the completed application. In addition, the Hold Harmless Agreement and the Medical Statement must be notarized. Incomplete applications will be rejected. Resumes are NOT accepted in lieu of a completed application. Applications remain active for six months after date of submission. SPECIAL NOTE about the Motor Vehicle Record form: There are two versions of this form – a Georgia Form and a South Carolina form. You only need to complete one of the two forms. Complete the form for the state that issued your driver’s license. After all completed forms have been submitted, your information will be reviewed, and you will be contacted regarding the results. Interviews are scheduled on a quarterly basis. Dive Team Application Page 1 Updated 06‐2017 ---PAGE BREAK--- APPLICATION FOR MEMBERSHIP Columbia County Dive Rescue and Recovery Team Name First MI Last Address Street # Street Name Apt# City State ZIP Code Driver’s License Number Expiration Date Contact Work Information Cell Home Cell Service Provider Email Alternate Email Have you ever worked with a Dive Team or in emergency services? If so, when, where, and what type of work did you do? Have you received any traffic citations in the past 3 years (Answer YES or NO)? If so, please indicate the type of offense and dates. Have you (since the age of 18) ever been convicted of or plead guilty or no contest to a misdemeanor (Answer YES or NO)? Have you (since the age of 18) ever been convicted of or plead guilty or no contest to a felony (Answer YES or NO)? If YES, describe the circumstances. ---PAGE BREAK--- APPLICATION FOR MEMBERSHIP Columbia County Dive Rescue and Recovery Team Name First MI Last Have you ever been suspended, dismissed or asked to resign from any job (Answer YES or NO)? If YES, explain in detail. Can you be released from your place of employment for Dive Team operations if necessary? Always_ Most always_ Occasionally Never Do you understand that the membership you are applying for is a volunteer position and that you will not receive any financial or material compensation for services rendered (Answer YES or NO)? Do you understand that your signature on this application gives your consent and authorization to the Columbia County Fire Rescue Dive Team Coordinator to have a background investigation conducted by an appropriate law enforcement agency (Answer YES or NO)? List any training, certifications, and/or experience you have in SCUBA diving, boating, or emergency services (such as: First Aid, CPR, SCUBA) that pertain to dive, rescue, and/or recovery. Statement of Applicant: I , certify that the information and statements made on this application are true and correct to the best of my knowledge. Signature: Date: ---PAGE BREAK--- 06/08/2011 1 STATE OF GEORGIA COUNTY OF COLUMBIA RELEASE AND HOLD HARMLESS AGREEMENT I, (name of applicant) being of lawful age, for myself, my representatives, successors or assigns, do hereby release and hold harmless and forever discharge COLUMBIA COUNTY (“County”), and their respective directors, officers, agents, employees, successors and assigns, and all other persons or organizations liable or who might be claimed to be liable from all actions, rights of actions, suits, claims, injuries, damages, and demands whatsoever, known and unknown, anticipated and unanticipated, past, present and future for any and all forms of damages, including all consequential and derivative damages resulting from or in any way growing out of the engagement of (name of applicant) to participate on the Columbia County Dive Rescue and Recovery Team (“Dive Rescue and Recovery Team”). I am a willing and voluntary participant on the Dive Rescue and Recovery Team. I understand that there are inherent risks involved in diving rescue and recovery, including, but not limited to, the failure of equipment, and risk of injury and death by drowning or other means. I further realize that diving rescue and recovery requires me to be in good physical condition. I hereby assume any risk to my health or property resulting from my participation on the Dive Rescue and Recovery Team. This instrument as read and understood contains the entire agreement between the parties without any inducement, promise or representation other than herein set forth. Undersigned hereby declares that the terms of this Release and Hold Harmless Agreement have been completely read and are fully understood and voluntarily accepted for the purpose of making a full and final release and discharge of any and all claims, disputed or otherwise, against the County on account of the damages and claims above mentioned, and for the express purpose of precluding forever any further or additional claims arising out of the aforesaid engagement and service of ’s (name of applicant) participation in the Dive Rescue and Recovery Team. ---PAGE BREAK--- 06/08/2011 2 RELEASE AND HOLD HARMLESS AGREEMENT IN WITNESS THEREOF, I have set my hand and seal this day of . 20 . Applicant SWORN TO AND SUBSCRIBED before me this day of , 20 Notary Public My Commission Expires: ---PAGE BREAK--- Columbia County Dive Team MEDICAL STATEMENT Participant Record (Confidential Information) 06/08/2011 Please read carefully before signing. This is a statement in which you are informed of some potential risks involved in scuba diving and of the conduct required of you during scuba activities. Your signature on this statement is required for you to participate in the Dive Team program offered by the Columbia County Fire Rescue Dive Team located in Columbia County, Georgia. Read and discuss this statement prior to signing it. You must complete this Medical Statement, which includes the medical- history section, to participate with the Columbia County Dive Team. Diving is a demanding activity. When performed correctly, applying correct techniques, it is very safe. When established safety procedures are not followed, however, there are dangers. To scuba-dive safely, you must not be extremely overweight or out of condition. Diving can be strenuous under certain conditions. Your respiratory and circulatory systems must be in good health. All body air spaces must be normal and healthy. A person with heart trouble, a current cold or congestion, epilepsy, asthma, a severe medical problem, or who is under the influence of alcohol or drugs should not dive. If taking medication, consult your doctor before participating in this program. You will also need to continually follow the important safety rules regarding breathing and equalization while scuba diving. Improper use of scuba equipment can result in serious injury. You must be thoroughly instructed in its use to use it safely. If you have any additional questions regarding this Medical Statement or the Medical History section, review them with the Dive Chief or your SCUBA instructor before signing. NO ONE UNDER THE AGE OF 18 YEARS WILL BE ALLOWED AS A MEMBER. MEDICAL HISTORY To the Participant: The purpose of this medical questionnaire is to find out if your doctor should examine you before participating in recreational diver training. A positive response to a question does not necessarily disqualify you from diving. A positive response means that a preexisting condition may affect your safety while diving and you must seek the advice of your physician. Please answer the following questions on your past or present medical history with a YES or NO. If you are not sure, answer YES. If any of these items apply to you, we must request that you consult with a physician prior to participating in scuba diving. The Columbia County Fire Rescue office will supply you with a Medical Statement and Guidelines for Scuba Divers Physical Examination to take to your physician. Could you be pregnant or are you attempting to become History of diving accidents or decompression sickness? pregnant? History of recurrent back problems? Do you regularly take prescription or nonprescription History of back surgery? medications? (with the exception of birth control) History of diabetes? Are you over 45 years of age and have one or more of the History of back, arm or leg problems following surgery, injury or following? fracture? currently smoke a pipe, cigars, or cigarettes Inability to perform moderate exercise (example: walk one mile within have a high cholesterol level 12 minutes) have a family history of heart attacks or strokes History of high blood pressure or take medicine to control blood Have you ever had or do you currently have: pressure? Asthma, or wheezing with breathing, or wheezing with exercise? History of any heart disease? Frequent or severe attacks of hay-fever or allergy? Frequent colds, sinusitis or bronchitis? Any form of lung disease? Pneumothorax (collapsed lung)? History of chest surgery? Claustrophobia or agoraphobia (fear of closed or open spaces)? Behavioral health problems? History of heart attacks? Angina or heart surgery or blood vessel surgery? History of ear or sinus surgery? History of ear disease, hearing loss or problems with balance? History of problems equalizing (popping) ears with airplane or mountain travel? History of bleeding or other blood disorders? Epilepsy, seizures, convulsions or take medications to prevent History of any type of hernia? them? History of ulcers or ulcer surgery? Recurring migraine headaches or take medications to prevent History of colostomy? them? History of blackouts or fainting (full/partial loss of consciousness)? Do you frequently suffer from motion sickness (seasick, carsick, etc.)? History of drug or alcohol abuse? The information I have provided about my medical history is accurate to the best of my knowledge. Participant’s Signature Date (day/month/year) ---PAGE BREAK--- Georgia Department of Driver Services Customer Service, Licensing and Records Division P.O. Box 80447 Conyers, Georgia 30013 REQUEST FOR MOTOR VEHICLE REPORT (MVR) I am requesting my own Georgia MVR. (Complete Sections 1, 3, and 4) X I am requesting a Georgia MVR of another individual. (Complete Sections 1, 2, 3, and 4) PLEASE PRINT LEGIBLY SECTION 1 – DRIVER INFORMATION (must exactly match driving record) Full Name (First, Middle, Last) Driver Date of Birth (MM/DD/YY) Driver’s License Number SECTION 2 – THIRD PARTY REQUESTOR INFORMATION Full Name (First, Middle, Last) Darlene M. Bartlett, Risk Manager Firm Name (if applicable) Columbia County Board of Commissioners Address P.O. Box 498, Evans, Georgia 30809 FOR DEPARTMENTAL USE ONLY SECTION 3 – TERM OF REQUEST Please choose one of the following options: X Three year Georgia MVR ($6.00 fee) Seven year Georgia MVR ($8.00 fee) If you are requesting a Georgia MVR by mail, please include a business sized self-addressed stamped envelope along with this request and the required payment amount. By mail, we accept personal checks, cashier’s checks, money orders, and company checks. SECTION 4 – AUTHORIZATION TO RELEASE RECORD OF DRIVER Under penalty of law, I hereby request release of my driving record; OR (please check one) X consent to release of my driving record to the person and/or entity named in Section 2, in accordance with O.C.G.A. §40-5-2. Signature of Driver Date (MM-DD-YY) DDS-18 (1/10) ---PAGE BREAK--- PART 1 South Carolina Department of Motor Vehicles Request for Driver Information MV-70 (Rev. 1/08) Part 1 must be completed before information listed on Parts 2 (single request) or 3 (multiple requests) will be released. Check the boxes of permissible uses that apply to you under Federal Law (18 USC, Chapter 123). Persons submitting this form to obtain someone else's record should read the Federal law before signing. See Part 3 of this form for how to find a copy of the law. Under Federal Law, driver personal information may be obtained only for certain uses. The following is a short version of permissible uses: 1. For use by any government agency in carrying out its functions. 2. For a business to verify the accuracy of personal information previously provided to the business. 3. To use in any court proceeding, or investigation in anticipation of litigation. 4. For research and statistical purposes so long as the personal information is not published, redisclosed, or used to contact individuals. (Such requests are processed only in DMV Headquarters. See special instructions on back of this form.) 5. For use by an insurer for claims investigations, rating and underwriting. 6. For use by an employer or their insurer to verify commercial driver license information. X 7. For any other use by the driver or by written consent of the driver. (See "Consent" in Part Under penalty of perjury, I state that I am entitled to receive and use this information as permitted under the Driver's Privacy Protection Act of 1994 (18 USC, Chapter 123 as amended). I further acknowledge that if I misuse this information or give it to someone who uses it for an unauthorized purpose, I may be subject to Federal criminal law as well as a civil lawsuit where the minimum award is $5,000.00. Columbia County Board of Commissioners Print Name of Person/Business Requesting Information Date P.O. Box 498, Evans, Georgia 30809 Address of Person/Business Requesting Information Darlene M. Bartlett, Risk Manager Print Name of Person Receiving Information Signature of Person Receiving Information PART 2 - To be used to obtain information on a single driver. Name DL/BP/ID # (if available) Date of Birth Information Requested: CONSENT: (only needed if Box 7 of Part 1 is checked) I, , give consent for the release of my personal information to Print name of Driver the person shown above. Signature of Driver Date REQUIRED FEES FOR EACH SEPARATE DOCUMENT: MAIL TO: Copy of MVR $ 6.00 Alternative Media Copy of Ticket/Suspension Notices $ 6.00 P.O. Box 1498 Other related documents $ 6.00 SC 29016-0035 Make check or money order payable to: S C Department of Motor Vehicles. (NO CASH ACCEPTED) OFFICE USE ONLY Identification presented by person receiving information Office Code Employee Processing Request Date ---PAGE BREAK--- “An Internationally Accredited Agency” COLUMBIA COUNTY SHERIFF’S OFFICE Clay N. Whittle, Sheriff 2273 COUNTY CAMP ROAD POST OFFICE BOX 310 APPLING, GEORGIA 30802-0310 (706) 541-1043 CRIMINAL HISTORY CONSENT FORM I, (Complete Full Name) hereby request to receive the Criminal History Record Information pertaining to me which may be in the files of the Georgia Crime Information Center relating to my record with any Criminal Justice Agency providing that information. I expressly release the Columbia County Sheriff’s Office from any and all liability claims relating to the acquisition and release of any information pertaining to me. Print the following information: Full Name: Address: City, State and Zip Code: Telephone: Sex: Race: Hair Color: Eye Color: Height: Weight: Date of Birth: Place of Birth: SSN: REASON FOR REQUEST: Child Abuse (DFCS) (Case # * Must Have a Copy of report attached Neglect (DFCS) Adoption Foster Care Alcohol License XX Other Special employment provisions (check if applicable) Employment with mentally disabled (Purpose code Employment with elder care (Purpose code Employment with children (Purpose code Employment with criminal justice agency – non-sworn (Purpose code Employment with criminal justice agency- sworn (Purpose code I hereby Certify, by my signature below, that all of the above information is TRUE. I further authorize the below listed individual to receive my Criminal History Record Information from the Columbia County Sheriff’s Office. Any alteration of this form after completion may lead to prosecution. SIGNATURE DATE NAME OF AGENCY / INDIVIDUAL TO RECEIVE RECORD PHOTO ID The official response to this request will bear a raised seal over the photo ID and a red ink stamp Signature Date THIS FORM MUST BE FILLED OUT COMPLETELY AND NOTARIZED FOR RELEASE OF INFORMATION NOTARY SIGNATURE DATE “An Equal Opportunity Employer”