KVFD Volunteer Program Application


KOTZEBUE VOLUNTEER FIRE DEPARTMENT APPLICATION FOR MEMBERSHIP

Date of Application:
Hire Date:
Name: D.O.B. SSN: / / P.O. Box: House#: Phone: (H) (W) Employer: Application for: 0 Fire 0 Ambulance 0 Both What would you like to do? What skills can you provide to the Fire Department? What type of training are you interested in? What training/certifications do you already have? When are you available to volunteer? Do you have a valid Alaska Drivers License? 0 YES 0 NO DL# Expiration Date: If you do not have a license, can you obtain one? 0 YES 0 NO Have you ever been convicted of a felony? 0 YES 0 NO Have you ever been convicted of a misdemeanor? 0 YES 0 NO If you answered yes to any of the last two questions, explain the circumstances, outcome and dates on a separate sheet of paper. I, herby apply for membership in the Kotzebue Volunteer Fire Department, and in so making application agree: 1. To abide by the rules and regulations of the department. 2. To obey the commands and instructions of my superior officers, to the best of my ability, while on the scene of an emergency, in the station and during all department activities. 3. To give freely of my time and energies, to the department, as I am able. 4. To be supportive of the department in community affairs, keeping in mind that health and safety of the citizens of Kotzebue and the prevention of fire are the primary tasks of all members of the department. 5. To maintain a professional attitude and patient confidentiality with regards to all emergency and non-emergency calls. 6. To abide by all State, Federal and OSHA requirements for emergency responders. In case of emergency, whom should we notify? NAME: RELATIONSHIP: PHONE#: (H) (W) Have you had the Hepatitis B vaccination series? (Check the appropriate box) NO 0 1 Shot 0 2 Shots 0 3 Shots 0 Diagnosed as immune Have you had the Hepatitis A vaccination series? (Check the appropriate box) NO 0 1 Shot 0 2 Shots 0 Diagnosed as immune By signing below I attest that I have filled out this application accurately and to the best of my knowledge, and give permission for the release of medical records to the Kotzebue Volunteer Fire Department, necessary to verify the above vaccination information. _______________________________________________________________________________ Signature of Applicant Date For Department Use Only Date of Review: BOARD APPROVAL: DATE: CHIEF’S APPROVAL: DATE: PRECEPTOR ASSIGNED: DATE: DATE PROBATION STARTED: DATE PROBATION REVIEWED: NOTES/COMMENTS:

If you are interested in joining our team and would like to chance to be a service to your community, click here: KVFD Membership Application (Word Doc).


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