Volunteer Firefighter Application Form
Hemstreet Park Fire dept
Personal Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Residence Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
Home/Work Phone
*
-
Area Code
Phone Number
License Number/state
*
If None input (NA)
Employers Name
Name
Employers Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What Type of response would you like to perform?
Fire
EMS
Water Rescue/Boat Operations
Hazardous Material Decon
Junior Firefighter program
Rope rescue
Fire police
Training
Driver
Other
Basic Requirements
Are you 14 years of age or older?
*
Do you possess a valid Unrestricted Driver’s License and a good driving record?
*
Do you have Past Fire /EMS experience?
*
If so where ?
Dept. Name
If so where ?
Dept. Name
If so where ?
Dept. Name
Are you willing to participate in Training drills, Fire alarms and Company meetings to the best of your abilities?
*
Do you understand that applicants will be required to undergo a Criminal Record Check for as required by law?
*
Do you believe you are free of medical conditions that may preclude your participation in the type of response noted above?
*
Are you willing to participate in a medical check required of potential volunteer firefighters?
*
Do you understand that some jobs require volunteer firefighters to be in good physical condition, and do you feel you are physically able to participate in a physical fitness related the job you want to perform as part of the selection process?
*
Do you understand that successful applicants are required to remain without facial hair to ensure a self-contained breathing apparatus mask will form a positive seal on the face?
*
Additional Comments
Availability
Please select your availability for the given days and time phases
*
Monday - Days
Monday - Nights
Tuesday - Days
Tuesday - Nights
Wednesday - Days
Wednesday - Nights
Thursday - Days
Thursday - Nights
Friday - Days
Friday - Nights
Saturday - Days
Saturday - Nights
Sunday - Days
Sunday - Nights
If accepted by the Fire Department, you will be required to attend to the best of your ability regular weekly Thursday night Training (approximately 7:00PM to 9:00PM). Can you meet this requirement?
*
Do you understand that in order to be available for emergency call-outs, you must be able to arrive at the fire station promptly and have abstained from alcohol and drugs for the previous 8 hours?
*
Are you willing and able to retain and wear an emergency pager and respond to emergencies?
*
Are you willing and able to participate in the occasional weekend training program to the best of your ability ?
*
Skills and Experience
Please indicate if you have any of the following skills or training
*
CPR - Cardiopulmonary resuscitation
Certified Trade - mechanic, electrician
Fire Safety Systems - alarms, extinguishers
Rescue procedure - Ice rescue, Water rescue, auto extrication
First Aid/ First Response / EMT
Knowledge of breathing apparatus - SCBA/SCUBA , etc
PAD/Defibrillation Training
Occupational Health & Safety and Training
FIRE Police
Auxillery
Other
Previous Emergency Volunteer Experience - Explain:
Previous Firefighter Experience – Explain:
References
Provide 2 References
Terms and Conditions
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: