Cumberland County, VA Volunteer Firefighter and EMS Provider Application Form

Cumberland County, VA Volunteer Firefighter and EMS Provider Application Form
Would like to volunteer for Fire, EMS and/or both?*
Volunteer Fire Stations*
Personal Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Driver's License Number*
Provide DL# as listed on Driver's License
Phone Number*

Area CodePhone Number
Home/Work Phone*

Area CodePhone Number
Email*
example@example.com
Residence Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Basic Requirements
Are you legally eligible to work in the United States?*
Are you 16 years of age or older?*
Do you possess a valid Driver’s License and a good driving record?*
Do you understand that applicants will be required to provide your Driver’s License ID Number and submit to Criminal Record Check through the VA Office of EMS?*
Do you believe you are free of medical conditions that may preclude your participation as a volunteer firefighter and/or EMS provider?*
Have you ever been convicted of a crime (to include moving violations)? If so, please list them below.*
Additional Comments
Availability
Please select your availability for the given days and time phases*

Monday - DaysMonday - NightsTuesday - DaysTuesday - NightsWednesday - DaysWednesday - NightsThursday - DaysThursday - NightsFriday - DaysFriday - NightsSaturday - DaysSaturday - NightsSunday - DaysSunday - Nights
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?*
Skills and Experience
Please indicate if you have any of the following skills or training*

CPRFirst AidVDFP or VAVRS EVOC Class 3EMT, EMT I, EMT PFirefighter Certifications (list below)Other
Previous Emergency Medical Experience - Explain and List Certifications:
Previous Firefighter Experience – Explain and List Certifications:
References
Provide a reference in the space below.
Provide a reference in the space below.
Provide a reference in the space below.
I declare that the above information is true to the best of my knowledge. I authorize the executive committee to review criminal background checks and motor vehicle reports for use during the application process. I understand that if any part of this application is found to be false, my application will be rejected and I will not be considered again for membership for this organization. I also agree, upon acceptance into membership, to abide by the constitution and by-laws and standing operating procedures and to obtain all training needed to remain a member in good standing.
Terms and Conditions
Date

MonthDayYear
Date
Signature
Email Validator*
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Cumberland County, VA Volunteer Firefighter and EMS Provider Application Form

Personal Information

Basic Requirements

Availability

Skills and Experience

References

Terms and Conditions