First Name:

Middle Initial:

Last Name:

Are you at least 18 years old?
yesno

Address:

City:

State:

Main Phone Number:

Email:

Education: (required)
High SchoolVocational ScholCollege/UniversityAdvanced Education

Fire/Rescue Experience: (required)
YesNo

If yes, please tell us the Fire Department, City/State, Highest Rank, and Assignment below:

EMS Training:
First ResponderEMTEMT-IVParamedicNone

Input which days you would be available to respond to emergencies for the following hours (if none, leave that section blank):

6 AM to Noon:

Noon to 6 PM:

6 PM to Midnight:

Mightnight to 6 AM:

Do you have any medical conditions that would prevent you from doing the physically demanding work of fire fighting? (required)
YesNo

Has your driver's license been suspended or revoked within the past five years? (required)
YesNo

Do you have health insurance coverage? (required)
YesNo

Do you have any felony convictions or DUI violations? (required)
YesNo

Do we have your permission to run a background check? (required)
YesNo

Are you willing to submit to a drug test? (required)
YesNo

In case of emergency, notify:

Relationship to you:

Their Phone Number:

PLEASE READ THE JOB DESCRIPTION BELOW IN ORDER TO ANSWER THE FINAL QUESTION.

JOB SUMMARY:
A volunteer firefighter protects lives and property through activities associated with fire prevention, fire suppression, hazardous materials, and emergency medical incidents as well as participates in the training and maintenance activities necessary to achieve that end.

ESSENTIAL JOB FUNCTIONS:
- RESPONDS promptly to fire alarms and other emergency calls to incidents when notified
- DRIVES fire apparatus and OPERATES pump and other equipment with fire fighting, rescue, salvage, and maintenance operations
- ENTERS burning buildings and ADVANCES charged and uncharged hose lines and APPLIES extinguishing agents to fires
- POSITIONS and CLIMBS ladders to gain access to upper floors for rescue
- COMMUNICATES effectively verbally by means of two-way radio and person-to-person as well as in writing through completion of various records, memos, and letters

PHYSICAL REQUIREMENTS
- Must be able to lift, move, and climb ladders
- Must have the agility to climb through rafters, on roofs, and crawl through tunnels
- Must be able to open and close valves and be able to advance with hose discharging water
- Must be able to run and drag a hose
- Must be able to grasp and safely use hand tools such as an ax, pike, pole, chain saw, shovel, etc

REQUIRED SKILLS
- Ability to respond quickly, use good judgment, under stress in hazardous situations, and maintain human relationships

After showing you the job description of a volunteer firefighter, do you know of any reason why you could not perform this work? (required)
YesNo

If yes, please explain:

I certify that all statements given on this form are true. I consent to the release of any information required to verify this information as true. I agree that I will obey all laws, rules, and regulation, and follow the operational guidelines as prescribed by the fire department. I live or work within 5 miles of the fire district of the fire department. I understand that I will be on probation for no less than 12 months and may be excused from the department without fault or liability.

Your (digital) Signature:
Date: