Roscoe Volunteer Fire Department

APPLICATION FOR MEMBERSHIP

Name ____________________________________________ Date___/___/____

Address ______________________________________

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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

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 ____________________________________________________