Brooklin Volunteer Fire Company · Brooklin Fire Department Application For Junior Membership

Thanks very much for your interest in the Brooklin Fire Department!

Please complete all fields in this application. We will be in touch with you and your parent or guardian shortly after you submit the form.

If you would like to discuss before completing the application, call:

Chief Sam Friend at 669-2469

or

Assistant Chief Tommy Morris at 619-3360

Name

*

Prefix

First Name

Last Name

Suffix

Middle name

Enter your middle name if you have one

Preferred nickname

Enter your preferred nickname if it differs from your first name

Mark all the ways that we can we use to contact you

*

check each method that we can use to contact you

Mobile phone

Personal email

Home phone

Work phone

Work email

Mobile Phone Number

Mobile phone carrier

FirstNet

ATT

Verizon

Sprint

US Cellular

T-Mobile

Consumer Cellular

Other

Personal Email

Verify Email

Work email

Verify Email

Home Phone Number

Work Phone

Besides being a student, are you employed?

*

Check all that apply

Student

Work for a business

Have my own business from home

Have my own business at another address

Other

Describe Other

What did we miss on our list?

Name of School

Enter the name of the place where you work or go to school

What is your current level of school?

What grade or program are you in?

Start Date

enter your start date as close as you can remember (doesn't have to be exact)

Physical Street Address where you currently live (not your mailing address)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Date you began living there

*

(mm/dd/yyyy)

Is this also your mailing address?

Yes

No

Home mailing address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Have you lived anywhere else in the last 7 years?

*

Yes

No

(2) Prior Home Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(2) Date you began living there

(mm/dd/yyyy)

(2) Date you stopped living there

(mm/dd/yyyy)

(3) Have you lived anywhere else in the last 7 years?

Yes

No

(3) Prior Home Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(3) Date you began living there

(mm/dd/yyyy)

(3) Date you stopped living there

(mm/dd/yyyy)

(4) Have you lived anywhere else in the last 7 years?

Yes

No

(4) Prior Home Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(4) Date you began living there

(mm/dd/yyyy)

(4) Date you stopped living there

(mm/dd/yyyy)

(5) Have you lived anywhere else in the last 7 years?

Yes

No

(5) Prior Home Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(5) Date you began living there

(mm/dd/yyyy)

(5) Date you stopped living there

(mm/dd/yyyy)

Does your Parent of Guardian know that you wish to join the fire department?

*

You will need their permission to join.

Yes, and they approve

Yes, but they don't approve at this time

No, but I will discuss with them soon

You may want to talk to them first

You may want to discuss your interest in the fire department with your parent(s) or guardian(s) before you submit this form. This form will automatically generate an email to them and they may not like to be surprised.

Assure them that you and they will meet with department leadership before you start to discuss what a junior membership entails and give them and you an opportunity to specify any activities that will be off-limits for you.

Feel free to contact Sam or Tommy at the numbers shown on the top of this page before you discuss with them if you would like any additional guidance.

Parent or Guardian name

*

First Name

Last Name

Personal Email of your parent or guardian

*

Verify Email

*

Work Email of your parent or guardian

Verify Email

What types of phones can we use to contact your parent or guardian??

*

check each type of phone that we can use to contact your emergency contact

Mobile

Home

Work

Parent of Guardian Mobile Phone Number

Parent of Guardian Home Phone Number

Parent of Guardian's Work Phone Number

Parent of Guardian's relationship to you

*

Parent

Guardian

Age and Health

Do you have a driver's license?

*

check each type of phone that we can use to contact your emergency contact

Yes I have a license

I have a learner's permit

I have neither a license nor a permit

Driver's License State

*

The state that issued your driver's license

Driver's License Number

*

enter your driver's license number

Driver's license expiration date

*

(mm/dd/yyyy)

Are you legally eligible to work in the United States?

*

Yes

No

Enter your date of birth

*

(mm/dd/yyyy)

Do you have any health issues that the Brooklin Fire Department should know about?

*

Yes

No

would you and your parent or guardian like to discuss them in complete confidence with the Department Physician?

Yes

No

Are you willing to have a physical exam completed by physician? This exam would be confidential and paid for by the department.

*

Yes

No

Are you vaccinated against hepatitis B?

*

Yes

No

Can you provide the department with a record of your hepatitis B vaccination?

Yes

No

Volunteer areas of interest

Please mark the firefighting tasks that interest you

Select any jobs in each category that would interest you

Interior firefighting (training only--no live fire for junior members)

Exterior firefighting

Engine pumping

Fire reports

Truck organization

Other

Please mark the medical response tasks that interest you

Select any jobs in each category that would interest you. NOTE that not all of these tasks require medical certification

EMT

EMS Training

EMS Support

Go-fer

Lift assist

Moral support

EMS reports

EMS supplies

Other

Mark the administrative tasks that interest you

Select any jobs in each category that would interest you

Public outreach

Parade duty

Bookkeeping

Fundraising

Inventory

Station organization

Other

List any other tasks that might interest you:

With proper training, would you be able to perform the essential functions of those jobs that you checked?

*

Yes

No

Can you be at the Brooklin Fire Station most Tuesday nights from 6:00 to 8:00?

*

Yes

No

Maybe once or twice a month

Have you ever been a member of a fire department, rescue squad or similar organization?

*

Yes

No

Name of previous fire department, rescue squad or similar organization

Town and State of previous fire department, rescue squad or similar organization

Name and rank of person at that agency that we can contact

Provide the name and rank of a leader at the previous organization that we can contact

Phone number of contact person at that agency

When did you start with that agency?

indicate the date that you started (approximate month and day are OK)

Are you still active with that agency?

are you an active member

Active member

Inactive member

No longer a member

When did you become inactive with that agency?

indicate the date that you became inactive (approximate month and day are OK)

Reason you are no longer active

Describe why you ceased to be active with that agency

Have you ever been a member of any additional fire department, rescue squad or similar organization?

*

Yes

No

Name of previous fire department, rescue squad or similar organization

Town and State of additional previous fire department, rescue squad or similar organization

Name and rank of person at that agency that we can contact

Provide the name and rank of a leader at the previous organization

Phone number of contact person

When did you start with that other agency?

indicate the date that you started (approximate month and day are OK)

Are you still active with that additional agency?

are you an active member

Active member

Inactive member

No longer a member

When did you become inactive with that additional agency?

indicate the date that you became inactive (approximate month and day are OK)

Reason you are no longer active with that additional agency

Describe why you ceased to be active with that agency

Please indicate all of your ACTIVE certifications:

check all that apply

Basic Firefighter (interior attack)

Firefighter 1

Firefighter 2

Wildland Firefighter

EMT First Responder

EMT-Basic

EMT-Intermediate

Paramedic

Other

Describe Other

Can you provide documentation of all certifications that you indicated?

Yes: All

Yes: Some

Maybe

No

Please describe why you may not be able to document all of your certifications

How did you hear about the Brooklin Fire Department?

*

Why do you wish to join the Brooklin Fire Department?

*

What can the Brooklin Fire Department gain from your membership?

*

What do you expect to gain from your membership?

*

Job History

List any jobs that you have currently or have had in the past

(1) Organization/Employer

Name of Organization / employer / business. Leave blank if none

(1) Job title / function

(1) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(1) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(1) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(1) Reason for leaving

(1) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(1) Name of supervisor

Name of current supervisor

(1) Supervisor's phone number

(1) Supervisor's email address

Verify Email

(1) Why would you rather we not contact this supervisor?

(2) Do you have another job to list?

Yes

No

(2) Organization/Employer

Name of Organization / employer / business. Leave blank if none

(2) Job title / function

(2) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(2) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(2) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(2) Reason for leaving

(2) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(2) Name of supervisor

(2) Supervisor's phone number

(2) Supervisor's email address

Verify Email

(2) Why would you rather we not contact this supervisor?

(3) Do you have another job to list?

Yes

No

(3) Organization/Employer

Name of Organization / employer / business

(3) Job title / function

(3) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(3) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(3) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(3) Reason for leaving

(3) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(3) Why would you rather we not contact this supervisor?

(3) Name of supervisor

(3) Supervisor's phone number

(3) Supervisor's email address

Verify Email

(4) Do you have another job to list?

Yes

No

(4) Organization/Employer

Name of Organization / employer / business

(4) Job title / function

(4) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(4) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(4) Reason for leaving

(4) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(4) Why would you rather we not contact this supervisor?

(4) Name of supervisor

(4) Supervisor's phone number

(4) Supervisor's email address

Verify Email

(5) Do you have another job to list?

Yes

No

(5) Organization/Employer

Name of Organization / employer / business

(5) Job title / function

(5) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(5) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(5) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(5) Reason for leaving

(5) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(5) Why would you rather we not contact this supervisor?

(5) Supervisor's phone number

(5) Supervisor's email address

Verify Email

(5) Name of supervisor

(6) Do you have another job to list?

Yes

No

(6) Organization/Employer

Name of Organization / employer / business

(6) Job title / function

(6) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(6) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(6) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(6) Reason for leaving

(6) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(6) Why would you rather we not contact this supervisor?

(6) Name of supervisor

(6) Supervisor's phone number

(6) Supervisor's email address

Verify Email

(7) Do you have another job to list?

Yes

No

(7) Organization/Employer

Name of Organization / employer / business

(7) Job title / function

(7) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(7) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(7) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(7) Reason for leaving

(7) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(7) Why would you rather we not contact this supervisor?

(7) Name of supervisor

(7) Supervisor's phone number

(7) Supervisor's email address

Verify Email

(8) Do you have another job to list?

Yes

No

(8) Organization/Employer

Name of Organization / employer / business

(8) Job title / function

(8) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(8) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(8) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(8) Reason for leaving

(8) Name of supervisor

(8) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(8) Why would you rather we not contact this supervisor?

(8) Supervisor's phone number

(8) Supervisor's email address

Verify Email

(9) Do you have another job to list?

Yes

No

(9) Organization/Employer

Name of Organization / employer / business

(9) Job title / function

(9) Employer Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

(9) Start Date

Using mm/dd/yyyy format, enter your start date as close as you can remember (doesn't have to be exact)

(9) Finish Date

Using mm/dd/yyyy format, enter your day there as close as you can remember (doesn't have to be exact). Leave blank if you are still there

(9) Reason for leaving

(9) OK to contact supervisor?

Yes

Only if absolutely necessary

No

(9) Why would you rather we not contact this supervisor?

(9) Name of supervisor

(9) Supervisor's phone number

(9) Supervisor's email address

Verify Email

Use this field if there any part of your background that you would like to explain.

We are not here to judge. Help us understand the situation.