~VOLUNTEERING~

THE CENTRAL CAMPBELL FIRE DISTRICT IS ALWAYS IN NEED OF THOSE INDIVIDUALS INTERESTED IN VOLUNTEERING AND SERVING THEIR COMMUNITY.  DUE TO THE LACK OF VOLUNTEERS AND AN EVER INCREASING VOLUME AND VARIETY OF RUNS WE RESPOND TO, HELP IS ALWAYS NEEDED AND APPRECIATED. 

                 AS A VOLUNTEER WITH THE CENTRAL CAMPBELL FIRE DISTRCT YOU MAY BE PARTICIPATING IN A VARIETY OF WAYS.  YOU MAY BE:  ENGINEERING A FIRE ENGINE, CLIMBING THE AERIAL LADDER, CUTTING HOLES IN A ROOF, CLEANING UP A FUEL SPILL, RESPONDING TO AN EMS RUN, TALKING TO OTHERS ABOUT FIRE SAFETY AND PREVENTION, ETC.  YOUR HELP GOES A LONG WAY! 

                 ALL VOLUNTEERS WILL RECEIVE A VARIETY OF BENEFITS.  THIS WILL RANGE FROM FREE UNIFORMS AND GEAR, TRAINING (EITHER LOCALLY OR THROUGHOUT THE STATE OF KY), DEPARTMENT DINNERS/AWARDS, REIMBURSEMENT INCENTIVES, AND MANY MORE! 

                 IF YOU ARE INTERESTED IN LEARNING MORE ABOUT WHAT YOU CAN DO AS A VOLUNTEER AND THE BENEFITS YOU CAN RECEIVE, PLEASE DROP BY THE FIREHOUSE AT 4113 ALEXANDRIA PIKE, COLD SPRING OR CALL 859-441-7631. 

                 IF YOU HAVE ANY ADDITIONAL QUESTIONS OR CONCERNS PLEASE CONTACT LT. JUSTIN SANER AT THE FIREHOUSE. 

Please Copy and Paste To Microsoft Word

CENTRAL CAMPBELL COUNTY FIRE DISTRICT  

VOLUNTEER APPLICATION 

PERSONAL INFORMATION 

Name  ________________________________________________________________________________________ 

                 (Last)                                                       (First)                                                       (M.I.) 

Address  ______________________________________________________________________________________ 

                                 (#, Street)                                                (Apt. #)                                    (City, State, Zip) 

E-Mail: _________________________________________________________ 

Telephone Numbers: 

                 Home (          ) _______-____________                          Work/Cell  (           ) _______-____________ 

Date of Birth _______/_______/_______    Soc. Sec # _______/_______/_______         FFN # ________________ 

Preferred Method of Contact:  Home Phone:             Cell/Work Phone:            Email:   

Have you ever been convicted of a felony or are in current litigation?           Yes                   No 

DESIRED RESPONSIBILITIES 

Please indicate the type of service you wish to provide to the department and list any training you have had in the area selected: 

Fire Suppression[____]  ___________________________________  EMS[____]  ___________________________ 

Public Education[____]  ___________________________________ Rescue Operations[____]  _______________ 

(Additional)____________________________________________________________________________________ 

OCCUPATIONAL BACKGROUND 

List the last three jobs you’ve worked at starting with the most current.  All listed occupations may be contacted for reference. 

Company Name___________________________________                 Job Title______________________________ 

Phone Number (           ) _____-_______              Supervisor____________________          Dates Worked______-______ 

Company Name___________________________________                 Job Title______________________________ 

Phone Number (           ) _____-_______              Supervisor____________________          Dates Worked______-______ 

Company Name___________________________________                 Job Title______________________________ 

Phone Number (           ) _____-_______              Supervisor____________________          Dates Worked______-______ 

RELATED FIELD BACKGROUND 

If you have ever been a previous member of a Volunteer Emergency Service Organization, list the following information below: 

                 Department Name____________________________________________________________________ 

                 Address________________________________________________________________________________ 

                                                         (#, Street)                                                                             (City, State, Zip) 

                 Telephone # (           ) _______-__________ 

                 Name of Chief or Training Officer___________________________________________________________ 

                 Reason for Leaving & Date of Separation_____________________________________________________ 

                 ______________________________________________________________________________________ 

List any previous titles you have held within the department:  ___________________________________________ 

Department Name____________________________________________________________________ 

                 Address________________________________________________________________________________ 

                                                         (#, Street)                                                                             (City, State, Zip) 

                 Telephone # (           ) _______-__________ 

                 Name of Chief or Training Officer___________________________________________________________ 

                 Reason for Leaving & Date of Separation_____________________________________________________ 

                 ______________________________________________________________________________________ 

List any previous titles you have held within the department:  ___________________________________________ 

EDUCATIONAL BACKGROUND 

Do you currently hold any certifications or degrees?                                 Yes                   No 

If yes, please list certifications as well as expiration dates if applicable:  ___________________________________ 

_____________________________________________________________________________________________ 

_____________________________________________________________________________________________ 

PLEASE ENCLOSE A COPY OF YOUR HIGH SCHOOL DIPLOMA, GED, AND/OR COLLEGE DIPLOMA(S) IF APPLICABLE              check if enclosed 

REFERENCES 

Below, give the names of three persons you are not related to, whom you have known for at least one year. 

EMERGENCY CONTACTS 

Please list the person(s) who should be contacted in case of an emergency. 

Other than attending regular fire drills, are you willing to attend specific fire schools to excel your knowledge and gain certifications, on a nightly or weekend basis?          Yes                                                                 No 

If No, please explain reasons you cannot attend:  _____________________________________________________ 

I hereby make application for volunteer membership and certification that statements made on this application  

and any other materials submitted with this application are true, under penalty of perjury.  I understand that  

Falsified or intentionally omitted information will be cause for denial or termination of my membership, as well as  

possible legal action. 

Signature:_________________________   Printed Name:________________________    Date:_____/_____/_____ 

DEPARTMENT USE ONLY, DO NOT FILL OUT 

Date Received:  _____/_____/_____                                                 Person Receiving:  __________________________ 

Background Papers Filed:  _____/_____/_____                               Initials:  _________ 

Comments:  ___________________________________________________________________________________ 

_____________________________________________________________________________________________ 

_____________________________________________________________________________________________ 

Approved:__________              Disapproved:__________              Date:_____/_____/_____ 

Authorization for Release of Records 

I, __________________________, hereby authorize the Central Campbell Fire District to request any law enforcement agency, former employer, or credit bureau to release all information (including but not limited to traffic violations and arrest/convictions) to the Central Campbell Fire District or it’s representative that may be sought in connection with my application for the position of volunteer firefighter with the Central Campbell Fire District. 

Social Security No. 

____________________________________________________  

Sex______         Race______      DOB_____/_____/_____ 

Scars, Marks, Amputations, Tattoos, etc. 

____________________________________________________  

Additional descriptive information may be provided to identify me if necessary or requested. 

A photocopy of this release shall be considered as effective as the original had executed copy. 

______________________________                                 __________ 

Applicants Signature                                                                                      Date 

______________________________                                 __________ 

Witness’s Signature                                                                                        Date 

______________________________                                 __________ 

Fire Department Authorization                                                                  Date