Hyalite Rural Fire District Volunteer Application

INDIVIDUAL DATA
Date of Application

MonthDayYear
Date
Last Name
First Name
Middle Initial
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship
Are there currently any criminal charges pending against you?

YesNo
Have you ever been convicted of a misdemeanor or felony?

YesNo
If "yes" to the above question, please explain (all accepted volunteers must complete a criminal background check and a credit history report):
Have you resided in another State?

YesNo
If "yes" to the above question, please list where and from what dates:

ADDITIONAL INFORMATION
How did you learn about the Hyalite Fire Department?
Why do you want to be a member of the Hyalite Fire Department?
Do you know anyone who has or is currenlty serving with the Hyalite Fire Department?

YesNo
If "yes" to the above question, please provide the name of person:

HEALTH
Have you reviewed the position description for which you are applying?

YesNo
Do you have any conditions (physical or mental) that may affect your performance as volunteer in any way?

YesNo
If "yes" to the above question, please describe:
Are you capable of performing in a reasonable manner the essential functions of the position, with or without a reasonable accommodation?

YesNo

APPLICANT'S STATEMENT

ACKNOWLEDGEMENT - AGREEMENT
I certify that all the information on this application is accurate and complete to the best of my knowledge and understand that misleading, false, incomplete, misrepresented statements will constitute sufficient cause for denying volunteer membership.

I understand that neither the acceptance of this application nor the subsequent entry into any type of relationship with the Hyalite Rural Fire District creates an actual or implied contract of employment. I understand that if I accept
a position it will be on a volunteer basis. This means that the Hyalite Rural Fire Departments or I have the right to terminate the relationship at any time, for any reason, with or without cause.

I authorize the Fire Department to investigate information concerning my education, employment experiences and all other aspects of my background relevant to my proposed volunteer position. I release the Hyalite Rural Fire
District and its members from all liability arising from such investigation. My signature indicates that I have read, understand and agree to all of the above.
Signature
*Non-Discrimination: The Hyalite Rural Fire District does not discriminate on the basis of age, race, color, national origin, sex, sexual preference, marital status, creed, or political belief, mental or physical handicap or disability, or status as a Vietnam era or disabled veteran in it employment/volunteer policies and practices.
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Hyalite Rural Fire District