Charlestown Fire District
Junior Firefighter Application Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Applying as (Please select one or both)
*
Junior Firefighter
Associate Member
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone
*
-
Area Code
Phone Number
Email
*
example@example.com
Junior Firefighter
Junior Firefighters are from 14 to 18 years of age, and with notarized parental consent, participate in training and firefighting activities, sometimes in a limited role depending on the incident. *(link to consent form below)
Are you 14 years of age or older?
*
Yes
No
Physical Condition
Do you understand that active volunteer firefighters are expected to be in good physical condition, and do you feel you are physically able to participate in a physical fitness related test as part of the selection process?
*
Yes
No
Are you willing to participate in a medical check if required to be considered as a potential active volunteer firefighter?
*
Yes
No
If your physical condition precludes your being an active volunteer firefighter, would you like to be considered for an associate membership?
*
Yes
No
Additional Comments
Availability
NOTE: Associate Members are not required to attend training sessions, respond to emergencies, and wear a pager.
If accepted by the Fire Department, you will be expected to attend regular monthly Tuesday night Training (approximately 7:00PM to 9:00PM). Can you meet this requirement?
*
Yes
No
If accepted by the Fire Department, you will be expected to attend regular monthly Sunday Training (approximately 9:00AM to 12:00PM). Can you meet this requirement?
*
Yes
No
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?
*
Yes
No
Are you willing and able to retain and wear an emergency pager and respond to emergencies?
*
Yes
No
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 - lifeguard, auto extrication
First Aid
Knowledge of breathing apparatus - scuba diving, etc
PAD/Defibrillation Training
Occupational Health & Safety
Other
Previous Emergency Volunteer Experience (if any) - Explain:
Previous Firefighter Experience (if any) – Explain:
Terms and Conditions
Date
-
Month
-
Day
Year
Date
Signature
Submit
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