GFD 420/Junior Firefighter Application

GFD 420/Junior Firefighter Application

Ages 12-17 | Updated 2026/01/22
Instructions for Applicants

Please read carefully and complete all required steps before submitting your application. Incomplete applications will be returned.
Steps to Complete Your Application
1. Complete all pages of this application in full.
2. Obtain a physical examination from your physician after acceptance into the
company. Your doctor must provide a signed medical statement confirming you are
physically fit to perform the duties of a firefighter.
3. If you are 14–17 years old, you must obtain working papers from your school. These
must be submitted with your completed application.
4. Applicants ages 12–17 must include Parent/Guardian Authorization Forms in
addition to this application.
Reference Materials:
Please review the following documents, available under the Recruitment tab at www.gbgfire.org:
• Pennsylvania Junior Emergency Service Program Compliance Manual
• GFD 420/Junior Firefighters Rules, Regulations, Policies, and Expectations
Application Checklist

Before submitting, confirm that you have included the following:
Completed Application
 Drug-Free Workplace Policy (signed acknowledgment)
 Working Papers (ages 14–17)
 Anti-Discrimination / Harassment Policy (signed acknowledgment)
 Physician’s Fit-for-Firefighting Medical Statement
 Photocopy of Operator’s License (if applicable)
 Parent/Guardian Authorization Form
 Waiver of Claims and Right to Sue (for 420 applicants only)

⚠Reminder: Applications missing any required documents will be returned.
Application Checklist

Before submitting, confirm that you have included the following:
Completed Application
 Drug-Free Workplace Policy (signed acknowledgment)
 Working Papers (ages 14–17)
 Anti-Discrimination / Harassment Policy (signed acknowledgment)
 Physician’s Fit-for-Firefighting Medical Statement
 Photocopy of Operator’s License (if applicable)
 Parent/Guardian Authorization Form
 Waiver of Claims and Right to Sue (for 420 applicants only)

⚠Reminder: Applications missing any required documents will be returned.

Applicant General Information
Full Government Name*

First NameMiddle NameLast NameSuffix
Date Of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Apartment/Suite/Duplex

CityState

Zip Code
Cell Phone*
Please enter a valid phone number.
Email
example@example.com
Driver's License or Photo ID State (if applicable)
Driver's License or Photo ID Number (if applicable)
Emergency Contact Information
Parent/Guardian Full Name*

First NameLast Name
Relationship*
Parent/Guardian Phone Number
Please enter a valid phone number.
Parent/Guardian Email
example@example.com
Parent/Guardian Consent

I hereby give permission for my child to apply for membership as a Junior Firefighter with the Greensburg Fire Department. I understand the duties and responsibilities that may be required and authorize participation in accordance with GFD rules and regulations.
Signature*

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Typed Name*
Date*

MonthDayYear
Date

References

(List three references who may be contacted.)
- Reference 1 Name*
  
  First NameLast Name
- Reference 1 Relationship*
- Reference 1 Address
  
  Street Address
  
  Apartment/Suite/Duplex
  
  CityState
  
  Zip Code
- Reference 1 Phone Number*
  Please enter a valid phone number.
- Reference 1 Email
  example@example.com
- Reference 2 Name*
  
  First NameLast Name
- Reference 2 Relationship*
- Reference 2 Address
  
  Street Address
  
  Apartment/Suite/Duplex
  
  CityState
  
  Zip Code
- Reference 2 Phone Number*
  Please enter a valid phone number.
- Reference 2 Email
  example@example.com
- Reference 3 Name*
  
  First NameLast Name
- Reference 3 Relationship*
- Reference 3 Address
  
  Street Address
  
  Apartment/Suite/Duplex
  
  CityState
  
  Zip Code
- Reference 3 Phone Number*
  Please enter a valid phone number.
- Reference 3 Email
  example@example.com

Fire Service History | List all previous fire departments you belonged to (if any). Include a supervisor name and contact number.
For each fire department you left or ended your membership, please state the reason for leaving.
Criminal History

Have you ever been convicted of a crime? If yes, provide details for each conviction
Include State, charge, and the disposition.
Do you have any certifications including any State, National, or Pro-Board Fire Service Certificates?*

YesNo
Do you have any physical or emotional limitations that would limit or prohibit you from performing the NFPA-defined duties and functions of a structural firefighter or emergency vehicle operator?*

YesNo
If yes to physical or emotional limitations, please explain.
Terms & Conditions

I, the undersigned applicant, swear and affirm that the information provided in this application is true and correct. I consent to any inquiries, background checks, or investigations necessary to verify the accuracy of the information provided. I understand that omissions or false statements may disqualify me from membership or result in dismissal and/or criminal charges.
Signature*

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Typed Name*
Date*

MonthDayYear
Date

Upload the front and back of your most recent photo ID or Driver's License.

Cancelof
Upload any previous fire service certifications as listed above.

Cancelof

Policy Sign Offs
Drug-Free Workplace Policy
The Federal Drug-Free Workplace Act became effective March 18, 1989. The following policy is instituted for the purpose of bringing the policies of Greensburg Volunteer Fire Department and its Companies into compliance with that law.

The unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance by the any Member/Volunteer on the premises of the City of Greensburg, the Greensburg Volunteer Fire Department and its companies or during any activity conducted, sponsored, or authorized by or on behalf of the Greensburg Volunteer Fire Department and its Companies is prohibited.

As a condition of membership, each Member/Volunteer must agree to:
1) Abide by the above statement; and
2) Notify the Board of Control and the Department Chief in writing of any criminal drug statute conviction for a violation occurring on the premises of the Greensburg Volunteer Fire Department, the City of Greensburg, or their Companies, or during a
Department/Company/City sponsored activity within five (5) days after the conviction.

Any Member/Volunteer found to be in violation of this drug abuse policy, at the discretion of the Greensburg Volunteer Fire Department, may be given leave or suspended, without any privileges or benefits, and, required to enter a drug rehabilitation program at the Member’s expense, or the Member/Volunteer may be terminated.

From time-to-time the Greensburg Volunteer Fire Department or its Relief Association may sponsor a workshop for the Members/Volunteers on the dangers of drug abuse. The Department’s ‘Infectious Control Officers’ have been designated as the contact person(s) of any Member/Volunteer who needs a referral to drug counseling or rehabilitation.
Anti-Discrimination/Harassment Policy
PURPOSE:
The purpose of this Policy is to clearly establish that the Greensburg Volunteer Fire Department of the City of Greensburg is committed to providing a positive and family-oriented work and social environment free from harassment and/or discrimination.

POLICY:
1) Any harassment or discrimination by a member, a visitor, or a vendor, on the basis of race, religion, national origin, ancestry, disability, medical condition, marital status, pregnancy, sexual orientation, gender, or age is explicitly a violation of State and/or Federal Law; and, such conduct will not be tolerated by the Greensburg Volunteer Fire Department or its Companies. Violations shall be subject to investigation and appropriate disciplinary action, including, but not limited to, discipline or termination from membership.

2) It is the responsibility of all Greensburg Volunteer Fire Department’s Administrative and Fire Operations Officers to enforce this policy.

3) Complaints shall be brought directly to the Department Chief, and his designated Administrative Officer(s).

4) It is the responsibility of each and every Fire Department Member/Volunteer/Worker to know this Policy and to follow this Policy. [See Greensburg Volunteer Fire Department SOG Section 802.]

5) Failure to advise of any observed or reported inappropriate or offensive interaction/relationship is in violation of this Policy. The Department/Company Officer (s) receiving such information shall immediately contact the President and Captain of said Company and/or the Department Chief and inform them of this incident/relationship.

6) False reports shall result in discipline.
By signing below,

you verify that the Applicant and Parent/Guardian both have read, understand, and agree to the Department “Anti-Discrimination/Harassment Policy”, and the "Drug Free Workplace Policy".
Applicant Name*

First NameLast Name
Applicant Signature*

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Date Signed

MonthDayYear
Date
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Signature*

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Date Signed

MonthDayYear
Date
What's Next:
If you wish to do so, you may print this form now using the buttons below.

PRIOR TO YOUR FIRST START DATE WITH YOUR COMPANY, YOU MUST VISIT WWW.GBGFIRE.COM/FORMS and complete forms "420 / Junior Member Parent/Guardian Authorization" and "Participation Agreement & Waiver of Claims and Right to Sue". These must be turned into the recruitment coordinator at RCarloni@gbgfire.com.

We will process your application and be in contact. Good luck, we look forward to working with you.
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GFD 420/Junior Firefighter Application

Instructions for Applicants

Application Checklist

Application Checklist

Applicant General Information

Emergency Contact Information

Parent/Guardian Consent

References

Criminal History

Terms & Conditions

Policy Sign Offs

Drug-Free Workplace Policy

Anti-Discrimination/Harassment Policy

By signing below,

What's Next: