Cumberland County, VA Volunteer Firefighter and EMS Provider Application
Would you like to volunteer for Fire, EMS, or both
Please Select
Fire
Ems
Both
Volunteer Fire Stations
Please Select
Cartersville Volunteer Fire
Cumberland Volunteer Fire
Randolph Volunteer Fire
Name
*
First Name
Last Name
Date of birth
*
/
Month
/
Day
Year
Date
Driver's License Number
As listed on Driver's License
Phone Number
*
-
Area Code
Phone Number
Home/Work Phone
*
-
Area Code
Phone Number
Email
*
example@example.com
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
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 submit to a Criminal Background check?
*
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 - 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
Do you understand that in order to be available for emergency call-outs, you must be able to arrive at the fire station/rescue squad 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
*
CPR
First Aid
VDFP or VAVRS EVOC Class 3
EMT, EMT I, EMT P
Firefighter Certifications (list below)
Other
Previous Emergency Medical Experience - Explain and List Certifications:
Previous Firefighter Experience – Explain and List Certifications:
References
* 2 References Required
Provide a reference in the space below.
*
Terms and Conditions
I declare that the above information is true to the best of my knowledge. I authorize the organization 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. 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.
Date
-
Month
-
Day
Year
Date
Signature
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