Volunteer Application
Contact Information
I'm interested in volunteering in the following roles:
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Firefighter
EMT
Ambulance Operator
Cadet
Name
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First Name
Last Name
Date of Birth
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Social Security Number
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Drivers License: State, Number, Class, & Expiration
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Emergency Contact: Name & Phone Number
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Employment and References
Present Employer
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Present Employer Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal References
Reference #1: Name, phone number, & email
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Reference #2: Name, phone number, & email
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Reference #3: Name, phone number, & email
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Other Information
Have you ever been convicted of any offense other than a minor traffic violation for which the fine was more than $50?
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Yes
No
Have you ever been convicted or been charged with a DUI violation under the vehicle code?
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Yes
No
Have you ever been charged with any violation of the Penal Code involving a felony or misdemeanor act of arson?
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Yes
No
If Yes, please explain:
Can you leave your employment to respond to alarms?
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Yes
No
Will you have any problems attending drills/training at a minimum of twice a month?
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Yes
No
Will you be able to attend the Mendocino County Chiefs' Academy? (An annual series of weekend trainings hosted by multiple Mendocino County fire departments, training new firefighters to a basic skill standard. Strongly recommended, not required.)
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Yes
No
I'm interested but I'd like more information.
Will you be able to take an EMT course? (A 6 unit class, offered through Mendo College.)
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Yes
No
I'm interested but I'd like more Information.
Do you have any physical and/or medical conditions that could affect your ability to perform essential job functions with or without accommodations? (AVFD will provide a third party medical examination to ensure applicant fulfills minimum physical standards while maintaining applicant’s privacy.)
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Yes
No
A volunteer on-call emergency responders could be called at a moment’s notice, therefore, alcohol and or recreational drugs may disqualify individuals from responding to emergencies and/or attending department activities. Impairment will affect job performance, your safety, and/or the safety of others. Will you be able to follow AVFD’s impairment policies?
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Yes
No
Do you currently use any illegal drugs?
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Yes
No
Have you ever been a member of another fire department/EMS service?
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Yes
No
If Yes, where?
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Current EMS Certification:
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None
CPR & AED for first responders
Title 22 First Aid
EMR
EMT
Paramedic
If Yes, provide copies of your current certifications with this file:
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Are you willing to commit positive time and energy to training, response and department activities?
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Yes
No
Are you willing to continually strive for excellence in AVFD’s service to our community and visitors?
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Yes
No
Please Read Carefully
I, the undersigned, hereby consent and agree that the Anderson Valley Community Services District may conduct such necessary background investigation for the purposes of determining my qualifications and fitness. I hereby authorized the release of information pertaining to, but not limited to, my education, driving record, police record, and prior employment. I hereby certify that all statements made on this application are true and complete, and that any misstatements of material facts will subject me to disqualification or dismissal from the Anderson Valley Volunteer Fire Department.
Signature of Applicant
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Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: