Volunteer Membership Application

Date

Personal Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

How long at current address?

Phone*

Social Security No.

Are you under age 18?*

Yes
No

Are you currently certified as an EMT in the State of South Dakota?*

Yes
No

If "No", are you nationally Registered by the NREMT?*

Yes
No

When could you start?

Educational Background

High School

Name of School	Location	Number of Years Completed	Degree

College

Name of School	Location	Number of Years Completed	Degree

Bus. or Trade School

Name of School	Location	Number of Years Completed	Degree

Professional School

Name of School	Location	Number of Years Completed	Degree

Have you ever been convicted of a crime which is substantially related to the functions or qualifications of the position for which you are applying?*

(a Conviction record will not necessarily disqualify you from membership)

Yes
No

If Yes, explain number of conviction(s), nature of offense(s) leading to conviction(s), how recently such offense(s) was/were committed, sentence(s) imposed and type(s) of rehabilitation.

Please enter name for release of the association to perform a background check at no cost to the applicant:

First Last

Date

Drivers License

Canton Volunteer Fire Department requires a valid drivers license to operate the trucks. Please complete the following section.

License Number

State of Issue

State

Classification*

Operator
Commercial (CDL)

Have you had any accidents during the past five years?*

Yes
No

If Yes, how many?

Have you had any moving violations during the past five years?*

Yes
No

If Yes, how many?

References

Please list two references other than relatives.*

Name	Position	Company	Phone

Use below space to elaborate on any background, experience, or qualifications that you believe should be considered in evaluating your qualifications for membership. You may include hobbies, volunteer experience and any other activities you believe relevant.

Please omit any information that would disclose your race, gender, age, marital status, ethnic origin, religious or political affiliations, or disability.

Fire Department Experience

1. Name of Department/Association

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Name of Last Chief

First Last

Date of Service

From

To

Job Title

Enter your last job title:

Reason for leaving (be specific)

List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this fire department.

Membership Description/Policy

Canton Volunteer Fire Department personnel are frequently required to lift heavy objects/persons. On-call status requires residing in the City of Canton or available and within the city limits. Association members are required to attend bi-monthly meetings and education. Confidentiality of service calls is mandatory at all times. Membership is contingent on majority vote of current members. A probationary period of three (3) months is in effect, during which time you may be disqualified as a member without recourse if the Canton Volunteer Fire Department feels your membership is not in the best for the fire department and/or the community of Canton.

Applicants agree to become a South Dakota Certified Firefighter within 2 years of application. This includes successfully taking required training classes, and associated tests.

The City of Canton, and the Canton Rural Association are the proprietors of the fire trucks and the Canton Volunteer Fire Department provides staff. Members are required to become familiar with all aspects of the fire department including operation, equipment location, and general maintenance.

Emergency response requires that are able to lift equipment, patients, etc., repeatedly. Do you have any limitations that would impede you from this requirement?*

Yes
No

Do you have any pre-existing medical or physical conditions that will interfere with performing emergency response, or fire fighting activities?*

Yes
No

If so, please provide documentation of course of treatment and name, address, and phone number of treating physician.

MD Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

After reviewing the above membership description, please indicate if you are able to perform the essential functions of the above described duties.*

Yes
No

If you answered "No", please identify any duties that you cannot perform. If a reasonable accommodation is required to enable you to perform the duties properly and safely, please describe:

Would your work permit you to answer fire alarms, the majority of the time, day or night?*

Yes
No

Would you be willing to make the Fire Department an important organization in your life, not just a social function, but realizing that human lives may depend on us, plus thousands of dollars worth of property?*

Yes
No

Would your spouse, or significant other, have objections of making the Fire Department an important organization in your lives together, knowing that a significant amount of time could be spend in meetings, training, fighting fires, etc., away from your family life?*

Yes
No

Our regular meetings are the first and third Mondays of each month. Would you be willing, and able, to attend these meetings on a regular basis?*

Yes
No

The Department asks that every new member spend at least three days each year at State Fire School, usually held the first of June. Would you able, and willing, barring unforeseen circumstances, to devote this time to attend?*

Yes
No

One Sunday each spring and fall, there is a District Fire School. Would you be able to attend these schools, on a regular basis?*

Yes
No

Certifications

Please complete below and submit copies, if available, of any fire fighting related courses you have completed.

Course

Date Completed

Location

Course

Date Completed

Location

Course

Date Completed

Location

CPR for Healthcare Providers or Red Cross equivalent

Date Completed

Please list any other specialty courses in which you are currently certified:

Course

APPLICATION FORM WAIVER

PLEASE READ CAREFULLY

In exchange for the consideration of my membership application by Canton Volunteer Fire Department:

Neither the acceptance of this application nor the subsequent entry into any type of membership relationship, either in the membership position applied for or any other position, and regardless of the contents of personnel manuals, policy statements and the like as they may exist from time to time, or other Canton Volunteer Fire Department practices, shall serve to create an actual or implied contract of membership, or to confer any right to remain a member of Canton Volunteer Fire Department, or otherwise to change in any respect the membership-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Fire Chief of the Fire Department. Both the undersigned and Canton Volunteer Fire Department may end the membership relationship at any time, without specified notice or reason. If membership is granted, I understand that the Canton Volunteer Fire Department may unilaterally change or revise their policies and procedures.
I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Canton Volunteer Fire Department permission to contact schools, all previous associations (unless otherwise indicated), references and others and hereby release the Canton Volunteer Fire Department from any liability as a result of such contract.
I understand that, in connection with the routine processing of your membership application, the Canton Volunteer Fire Department may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics and mode of living. Upon written request from me, the Canton Volunteer Fire Department, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.
I further understand that my membership with the Canton Volunteer Fire Department shall be probationary for a period of ninety (90) days and further that any time during the probationary period or thereafter, my membership relationship with the Canton Volunteer Fire Department is terminable at will for any reason by either party.

*

I agree that I have read and understood each of the above sentences.

Name of Applicant

First Last

Date

Canton Volunteer Fire Department does adhere to a policy of making membership decisions without regard to race, color, religion, gender, sexual orientation, national origin, citizenship, are or disability. We assure you that your opportunity for membership with Canton Volunteer Fire Department depends solely on your qualifications.

Canton Volunteer Fire Department Membership Application

Personal Information

Educational Background

Drivers License

References

Fire Department Experience

Membership Description/Policy

Certifications

APPLICATION FORM WAIVER