Volunteer

Butte Valley Fire Protection District

APPLICATION FOR MEMBERSHIP

Name: ______________________________                    Date: ______________

                           (Please Print)

Address: ____________________________                     Phone (H): ___________

         ______________________________                    Phone (M): ___________

         ______________________________

Driver Lic. #:________________ S.S.#:_____________      Birthday:________________

Do you have any firefighting, rescue or medical experience?  Y / N

         (Not a requirement) If Yes explain what type of experience

Are you willing to come to training sessions or work days offered?  Y / N

Are you certified in any of the following?  (Circle one)  Firefighter  EMT  1st Responder  CPR

Do you hold any instructors certificates?  Y / N

Are you able to respond during the daytime?  Y / N

Can you reach the station within 15 minutes while obeying traffic laws?  Y / N

Are you available to respond on most nights and weekends?  Y / N

Have you had any moving violation traffic tickets in last 3 years?  Y / N  If so explain

Have you ever been convicted of a felony offense?  Y/N

Have you ever been a member of another volunteer fire department?  Y / N

         If yes, what department?_______________________________

Have ever been removed or resigned from another fire department?  Y / N

         If yes, what department?___________________  Reason?__________________

Do you have any medical or health problems, or a physical handicap that would prevent you preforming stressful and vigorous firefighting activities, i.e. blood pressure, heart problems, etc)?    Y / N – If Yes there are still a need for support positions such as dispatch, fire preventions and other fire/rescue positions

In the event of an accident, injury or death, you realize that upon signing this application and you are accepted as a member, you are releasing the BVFPD and any officer or member of any further liability to you or your family.  ___________ write in Yes or No

Do you understand that any false information on this application , or any willful misconduct, disregard for our written policies or the Standard Operation Guidelines, could lead to your being removed from the department?  Y / N

IF ACCEPTED FOR MEMBERSHIP, YOU WILL BE ON A 6 MONTH PROBATION PERIOD

Applicant Signature