Firefighter Application

Firefighter Application

Hummels Wharf Fire-Rescue
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Emergency Contacts
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relation*
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relation

References

Please provide non-family references
Reference #1*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relation*
Reference #2*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relation*

Medical Information
Primary Care Physician*
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Hospital*
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
Please list all Medical Conditions*
YesNo
Medications List (Name, Mg and Times a day)*
YesNo
Please list all Allergies*

Criminal Background
YesNo
Please list the date(s) and what the charge(s) was/were:*

Your Interests
What interests you the most about becoming involved with the Fire Department?*
Please list other activities, in detail, that you are involved in (sports, Volunteer work, church, etc.)*

Past Experience
YesNo
Organization 1*

Department NameCity
Email
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Organization 2

Department NameCity
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Organization 3

Department NameCity
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Background Checks

Background checks are State Mandatory
If you do not have your Clearances completed. You may do so with the following links

PSP Background Check
https://www.dhs.pa.gov/KeepKidsSafe/Clearances/Pages/Criminal-Background-Check.aspx

Child Abuse Clearances
https://www.dhs.pa.gov/KeepKidsSafe/Clearances/Pages/PA-Child-Abuse-History-Clearance.aspx
Child Clearances*

Cancelof

Acknowledgments & Consent
YOUR APPLICATION WILL STILL HAVE TO GO THROUGH A MEETING

Initial membership petition is $20

Membership petition can be obtain by an active Firefighter or in our Social Club
Parental Consent:

My son/daughter has my permission to be a Junior Firefighter with the Hummels Wharf Fire Department. I give my consent to allow my child   First Name*   Last Name*   to be a Junior Firefighter and do not hold the Hummels Wharf Fire Department and First Responders or Monroe Township responsible for any actions caused by my son/ daughter that is not under the direction of an Officer. I acknowledge that I and my son/daughter have received a copy of the Hummels Wharf Fire Department Junior Firefighter Time Restrictions and have reviewed them prior to signing these documents.

Parent/Guardian Signature and Date:
Signature*   Date*

Junior Firefighter Signature and Date:
Signature*   Date*
Contract of Understanding

I and my son/daughter have read ALL of the Junior Firefighter Guidelines and understand the guidelines set up to outline the purpose of the Junior Firefighters. I and my son/daughter understand that Junior Firefighters serve as supporters of the Hummels Wharf Firefighters to learn the basics of firefighting and to prepare to become a full member at the age of 18. I and my son/daughter understand that Junior Firefighters are to follow all instructions from members of the HWFD and that the general standard of conduct is to act in the manner of a professional. I and my son/daughter understand that he/ she is expected to be courteous and respectful of other members (Junior and Regular) and to all citizens as they are representing the Hummels Wharf Fire Department. I and my son/daughter understand there is a “zero tolerance” policy regarding drug and alcohol use. I and my son/daughter understand that by signing this Contract of Understanding we are declaring that any violation of the guidelines is grounds for immediate dismissal. I and my son/ daughter understand that any acts that violate the guidelines and that are illegal by state law will be referred to the Pennsylvania State Police.

Parent/Guardian Signature and Date:
Signature* Date*

Junior Firefighter Signature and Date:
Signature* Date*
Acknowledge Receipt of Guidelines

I acknowledge that I and my son/daughter have received a copy of the Hummels Wharf Fire Department Junior Firefighter Program Guidelines and have reviewed them prior to signing these documents.

Click HERE to view and download document

Parent/Guardian Signature and Date:
Signature* blank*

Junior Firefighter Signature and Date:
Signature* Date*
Junior Firefighter Program Image and Materials Release & License

For good and valuable consideration herein acknowledged as received, I hereby grant to the Hummels Wharf Fire Department (HWFD), its legal representatives and assigns, and those acting with its authority and permission, the absolute right and permission to use, re-use, publish, and re-publish photographic portraits or pictures or videos of me and/or my child or in which I or my child may be included, in whole or in part, or composite or distorted in character or form, without restriction as to changes or alterations, made through any medium and in any and all media now or hereafter known. For purposes of illustration but not limitations in print materials, HWFD promotions and/or advertisements, public service announcements, public presentations, online, public displays, internal uses, art, trade, or any other purpose whatsoever. Additionally, if recorded my or my child’s voice may be used in conjunction with any other permitted use set forth in this agreement. I understand that my child’s name may be used in any publication; and my child’s school name, grade level, and/or age may also be used.

I further grant HWFD an irrevocable, royalty free, worldwide, all media license to use any material created by me or my child in conjunction with the activities of or in association with HWFD, for purposes of illustration but not limitations in artworks, essays, evaluations, etc.

I hereby waive any right that I may have to inspect or approve the finished product or products that may be used in connection therewith or the use to which it may be applied. I understand and agree that no further consideration is due me or my child from HWFD for the rights granted herein.

I hereby release, discharge, and agree to hold harmless HWFD, its legal representatives and assigns, and all persons
acting under its permission or authority or those for whom it is acting, from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said picture or in any subsequent processing thereof, as well as any publication thereof, including without limitation any claims for libel or invasion of privacy.

I hereby warrant that I am of legal age and have the right to contract in my own name and on behalf of my child. That no additional permissions are required. I have read the above authorization, release, and agreement, prior to its execution, and I am fully familiar with the contents thereof. This release shall be binding upon me and my heirs, spouse, my child’s other parents or guardians, legal representatives, and assigns. The term “Child” as used in this agreement shall be my natural born children, adopted children, or children for which I am legal guardian or foster parent.

Childs name:   First Name   Last Name
Childs School:
Grade:       Age

Parent/Guardian Signature and Date:
Signature
Please verify that you are human*
Signature*
Should be Empty:

Firefighter Application

Emergency Contacts

References

Medical Information

Criminal Background

Your Interests

Past Experience

Certifications

Background Checks

Acknowledgments & Consent

Parental Consent:

Contract of Understanding

Acknowledge Receipt of Guidelines

Junior Firefighter Program Image and Materials Release & License