Roscoe Volunteer Fire
Department
APPLICATION FOR MEMBERSHIP
Name ____________________________________________
Date___/___/____
Address ______________________________________
_____________________________________________________=
___________________
_____________________________________________________=
___________________
Phone (Days) ______________
(Night)=
________________________
(Mobil)________________________
TX DL#_____________________________ (Pager)_______________________
DATE OF BIRTH _________ Social Secur=
ity
#_________________________
Do you have any firefighting, rescue=
, or
medical experience? Y / N (NOT a requirement, We have training) If yes expl=
ain
what type experience and what department or Group..
_____________________________________________________=
___________________
_____________________________________________________=
___________________
_____________________________________________________=
___________________
Are you willing to come to training
sessions and or work days when offered? Y / N
Are you certified in any of the foll= owing? (circle any held) Firefighter EMT-P EMT ECA CPR<= o:p>
Do you hold any instructor certifica=
tes? Y
/ N
Are you available to respond during =
the
daytime? Y / N
Are you available to respond to the
station within a 15 minute driving time while obeying all traffic laws? Y /=
N
Are you available on most nights and
weekends to respond? Y / N
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=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=3D=
=3D=3D=3D=3D
Have you had any moving violation tr=
affic
tickets in the last 3 yrs? Y / N If so, explain
____________________________________=
_______________________________________
_____________________________________________________=
___________________
_____________________________________________________=
___________________
Have you ever been convicted of a fe=
lony
offense? Y / N
Are you now or have you ever been a =
member
of another VFD? ______ If yes, what dept
_____________________________________________________=
___________________
Have you ever been removed or asked =
to
resign from another volunteer department? Y / N
If Yes, what department?
_____________________________
Reason
_____________________________________________________=
___________________
_____________________________________________________=
___________________
Do you have any medical problems or = health problems or physical handicap that would prevent you from extremely stressf= ul and vigorous firefighting activities? (ie High Blood Pressure, Heart Problem, previous heart problems, etc) Y / N ___= _ If yes, you still could be used for support such as dispatch, fire prevention, and other non fire/rescue operations. In the eve= nt of an accident, injury or death during a RVFD official activity, do you agr= ee that you will not hold the Roscoe Volunteer Fire Depart= ment or any officer or member thereof either liable or financially responsible?<= o:p>
Do you also agree that you would not=
bring
a lawsuit against the same parties in such an event?
__________________
Please write in yes or no.
Do you realize that upon signing this
application and you are accepted as a member you are releasing the VVFD and=
any
officer or member of any further liability to you or your family, in the ev=
ent
of an accident, injury or death as the result of any VVFD official activity?
__________
Write in yes or no.
Do you understand that any false
information on this application or any willful misconduct or disregard for =
our written
constitution and by-laws, or the Standard Operation Procedures could lead to
your being removed from the department? Y/N
IF ACCEPTED FOR MEMBERSHIP, YOU WILL=
BE ON
A PROBATION PERIOD FOR 6 MONTHS?
Signed by ____________________________________________________