Junior Firefighter Interest Application

Date of Application

Date

Junior Firefighter Applicant's Name

First NameMiddle NameLast NameSuffix

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Junior Firefighter Applicant's Email

example@example.com

Junior Firefighter Applicant's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender

Date of Birth

Date

Parent or Legal guardian's name, if you are under 18 years old.

First NameMiddle NameLast NameSuffix

Parent or Legal guardian's phone number.

Please enter a valid phone number.Format: (000) 000-0000.

Parent or Legal guardian's email

example@example.com

I. Consent for Participation

I, the parent or legal guardian, being the parent or legal gauradian of the minor named above, hereby grant permission for my child to participate in the Stedman Volunteer Fire Department (SVFD) Junior Firefighter Program.

I understand that this program involves supervised training, community service, and educational activities related to fire and rescue services. I acknowledge that participation is a privilege and requires adherence to all SVFD and North Carolina Junior Firefighter Program rules.

II. Scope of Activities & Restrictions

Per North Carolina Department of Labor and OSFM guidelines, I understand that my child WILL NOT be permitted to:

- Enter a burning structure or "IDLH" (Immediately Dangerous to Life or Health) atmosphere.

- Operate hydraulic rescue tools (e.g., "Jaws of Life") or heavy power saws.

- Drive any fire department vehicles.

- Perform duties on a ladder higher than 10 feet.

- Respond to hazardous materials (Hazmat) incidents.

Permitted Activities include: Supervised training, clearing hydrants, rolling hose, rehabilitation support at scenes (outside the hot zone), and department meetings.

(A copy of NC OSFM Junior Program Standard will be provided for your records.)

III. Medical Authorization

In the event of an injury or medical emergency during SVFD activities, I hereby authorize the officers or members of the Stedman Volunteer Fire Department to seek and provide necessary medical treatment. -

Emergency Contact Name

First NameMiddle NameLast NameSuffix

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Known Allergies/Conditions

IV. Release of Liability

I recognize that fire-related training carries inherent risks. On behalf of my child and myself, I hereby release, discharge, and hold harmless the Stedman Volunteer Fire Department, its officers, the Town of Stedman, and the County of Cumberland from any and all claims, demands, or causes of action arising out of my child's participation in this program.

V. Academic Requirement & Specifics

The SVFD Junior Firefighter Program emphasizes education. I agree to allow the Fire Chief or Program Coordinator to periodically verify my child's school attendance and academic standing to ensure they remain eligible. Please provide the school's name, who to contact to obtain grade information, and current GPA.

School Attending

School contact name for reference

School contact phone number

Please enter a valid phone number.Format: (000) 000-0000.

Current GPA

VI. Equipment Accountability

I understand and agree that all Personal Protective Equipment (PPE) and department gear issued to my child remains the exclusive property of the Stedman Volunteer Fire Department. All equipment must be returned in good condition within 48 hours of exiting the program. I acknowledge that SVFD reserves the right to seek legal and/or financial restitution for any equipment not returned.

VII. Media Release

I hereby grant the Stedman Volunteer Fire Department permission to use photographs and/or video recordings of my child taken during program activities for the purposes of department recruitment, community outreach, and social edia presence.

Signature