WSVFD Junior Membership Application

WSVFD Junior Membership Application

Active Junior Firefighter
DATE

MonthDayYear
Today's Date
APPLICANT'S NAME

First NameLast Name
STREET ADDRESS

Street Address Line 2

CityState / Province

Postal / Zip Code
CITY, STATE, ZIP

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH

MonthDayYear
Date
EYE COLOR
HAIR COLOR
APPLICANT'S CONTACT NUMBER
Format: (000) 000-0000.
EMERGENCY CONTACT NAME
PARENT / GUARDIAN INFORMATION
FATHERS NAME

First NameLast Name
ADDRESS

Indicate if same as applicant

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH

MonthDayYear
Father's DOB
CONTACT NUMBER
Format: (000) 000-0000.
MOTHERS NAME

First NameLast Name
ADDRESS

Indicate if same as applicant

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH

MonthDayYear
Mother's DOB
CONTACT NUMBER
Format: (000) 000-0000.
LEGAL GUARDIAN

First NameLast Name
FAMILY/LEGEAL RELATION
ADDRESS

Indicate if same as applicant

Street Address Line 2

CityState / Province

Postal / Zip Code
DATE OF BIRTH

MonthDayYear
Date
CONTACT NUMBER
Format: (000) 000-0000.
MEDICAL INFORMATION
WHAT IS YOUR GENERAL HEALTH CONDITION?
DO YOU HAVE ANY CONDITION THAT WOULD LIMIT YOUR ABILITY TO SAFLEY PERFORM AS AFIRE FIGHTER ?
IF YES PLEASE EXPLAIN.
ALLERGIES
If none please enter "NA"
ALLERGY MEDICATION
If none please enter "NA"
HAVE YOU SEEN PHYSICIAN WITHIN THE PAST YEAR?
IF YES WHAT WAS THE REASON?

PARENT/GUARDIAN AGREEMENT
I grant permission for my child/ward to participate in the activities of the White Stone Volunteer Fire Department as set forth in Section 2-3 of the Town of White Stone.

I understand that my child will undergo training and participate as a firefighter within the department and that the White Stone Volunteer Fire Department, the Town of White Stone, and the officers of both the White Stone Volunteer Fire Department and the Town of White Stone are held harmless in the event of injury or death.

This permission also includes authorization for my child/ward to work the various fundraisers and participate in activities not related to the operational side of the department.
NAME OF PARENT/GUARDIAN SIGNING
PARENT/GUARDIAN SIGNATURE
DATE

MonthDayYear
Today's Date
I agree to attach a copy of my driving record and criminal history with this application. Once the records have been reviewed by the President and the Vice President of the department, the records will be returned to me.

I also agree to submit to random drug screening.
File Upload: Driving Record

If not applicable, don't upload any documents
Cancelof
File Upload: Criminal Record

If not applicable, don't upload any documents
Cancelof
APPLICANT SIGNATURE
DATE

MonthDayYear
Today's Date
Should be Empty: