Application For Membership

Name

First Last

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone #

Cell Phone #

E-mail Address

Number Of Dependants

Married

Yes

Social Security #

Driver's License #

Driver Insurance Company and Policy #

If you do not have a valid driver's license please explain

Other then a minor driving violation (speeding, etc.) have you been arrested or convicted of a felony?

Yes

Do you have any physical or mental handicap that prevents you from performing stressful work?

Yes

If yes, this handicap must be discussed in private with the Fire Chief and Chief Medical Officer of the department before this application can be processed.

Do you have any previous Fire or Emergency Medical Service experience or training?

Yes

Explain what fire or emergency medical experience or training you have had.

Fire

EMS

Haz Mat

Incident Management

Other related Training

Submit any and all documentation and certifications of Fire, EMS, Haz Mat, or other related training. Application will not be accepted without documentation.

Rate the following tasks / jobs you feel you can accomplish with your present knowledge or experience:
1 - Very Comfortable
2 - Comfortable
3 - Need Training
4 - Not Comfortable
5 - Not Willing To Do

Confined Space: working in tight spaces

1 - Very Comfortable

2 - Comfortable

3 - Need Training

4 - Not Comfortable

5 - Not Willing To Do

Working in low or cold temperatures

1 - Very Comfortable

2 - Comfortable

3 - Need Training

4 - Not Comfortable

5 - Not Willing To Do

Working in high or hot temperatures

1 - Very Comfortable

2 - Comfortable

3 - Need Training

4 - Not Comfortable

5 - Not Willing To Do

Working on ladders over 10 foot high

1 - Very Comfortable

2 - Comfortable

3 - Need Training

4 - Not Comfortable

5 - Not Willing To Do

Are you fearful of heights?

1 - Very Comfortable

2 - Comfortable

3 - Need Training

4 - Not Comfortable

5 - Not Willing To Do

Do you work well with others?

1 - Very Comfortable

2 - Comfortable

3 - Need Training

4 - Not Comfortable

5 - Not Willing To Do

Are you fearful of blood and other distasteful images?

1 - Very Comfortable

2 - Comfortable

3 - Need Training

4 - Not Comfortable

5 - Not Willing To Do

Are you able to respond to fires and other emergencies during the

Day

Night

What hours do you currently work?

What days do you currently work?

Can you attend Business Meetings on 2nd Tuesday of each month?

Can you attend Training Meetings on Last Thursday of each month?

On acceptance into the Fire Department you are required to submit to the Training Officer all Fire and Emergency Medical Training records and certificates issued to you. These documents are required to ensure your level of training and expertise is in compliance with State of Indiana Department of Homeland Security and Shawswick Volunteer Firefighters Association rules and regulations.

As an applicant for the Shawswick Volunteer Firefighters Association, I understand that I may be selected for one of two membership positions.

1. Firefighter

Article VIII, Section II of the Official By-Laws
a. Within (1) one year all new members shall complete Mandatory Firefighter training.
b. Within (2) two years the candidate shall complete training and achieve certification at the levels of Firefighter 1 and 2, Hazardous Materials Awareness and Hazardous Material Operations.
c. The cost of this training shall be provided by Shawswick Fire Department. These courses are offered on as needed basis by this department.
d. After serving the probationary status of (1) one year on the department each new member shall complete the Indiana First Responder Course. This course will provide instruction in the approach to Basic Life Support Care.
e. The cost of taking this program will be reimbursed by the department after successful completion and achieving certification. Funding restraints shall be considered by the department for the number of applicants admitted to the program.
f. All members of this department shall achieve certification in the American Heart Health Care Provider CPR. This training shall be provided by the department.
g. All members of the department shall complete an Emergency Vehicle Operation Course (EVOC) when offered by the department. NO member shall drive any vehicle owned and operated by the department without having an EVOC certification. At the discretion of the Fire Chief.
h. Emergency Medical Technician (EMT) Basic Training may be offered to members of the department at the discretion of the Board of Directors and funding restraints at the time of the request. See Article VIII, Section II of the By-Laws for reimbursement requirements and seniority status.
i You are required to attend all business meetings, all training meeting and other requirements as defined by the department Fire Chief.
j. You are also required to respond to all fire and emergencies as defined by the department mission statement and your level of training.

2. Junior Firefighter

(a) To be accepted as a Junior Firefighter the candidate must be 16 years of age.
(b) The Mother or Father of the candidates' immediate family must be a member of Shawswick Fire Department.
(c) You will assist the core fire fighting team with all station duties.
(d) You will be assigned a station for duties (mowing, cleaning the station and vehicles).
(e) You will be required to assist with training and other duties except responding to an actual fire or other emergency incident or scene.
(f) This position will be considered first when selecting new applications for Firefighter status when the candidate has reached 18 years of age.

I understand a driver's license check and background check will be conducted, at my expense, by an appropriate law enforcement agency.

I understand

I must provide a copy of my vehicle driver's insurance to the Fire Chief of the department.

I understand

I understand I must pass an annual mandatory drug screen test to be conducted by a medical facility contracted by the fire department.

I understand

I understand I must pass an annual physical examination to be conducted by a medical facility contracted by the fire department.

I understand

I hereby certify that the above answers are true to the best of my knowledge.

I understand

I hereby certify that no promise of payment of money or other consideration has been made to me.

I understand

I understand that service in the Shawswick Volunteer Firefighters Association is entirely Volunteer and as a Non-Paid Status.

I understand

Signature of Applicant

Sponsor of Applicant (if under 18 years of age Mother or Father must be a member of SVFD)

Investigating Committee

Approved for Membership

Disapproved

Investigating Committee

Approved for Membership

Disapproved

Application submitted to Fire department Date:

First Reading for Membership Date:

Application for Membership Accepted Date:

Second Reading for Membership Date:

General Membership Vote for Membership Date:

Board Reading and Discussion on Application Date:

Board Vote for Membership Date:

Accepted into Fire Department Date:

President Shawswick VFD

Date

Fire Chief Shawswick VFD

Date