MEMBERSHIP APPLICATION

Transcription

1 GIBSONS & DISTRICT VOLUNTEER FIRE DEPARTMENT 790 North Rd. PO Box 8, ph (604) Gibsons, BC V0N 1V0 fax (604) MEMBERSHIP APPLICATION DATE: LAST NAME: MIDDLE NAME(S): FIRST NAME: PREFERRED NAME: STREET ADDRESS: MAILING ADDRESS: ADDRESS: HOME PHONE #: MOBILE PHONE #: BIRTH DATE: BC HEALTH INSURANCE #: DRIVERS LICENSE #: SIN: MARITAL STATUS: CLASS: AIR BRAKE ENDORSEMENT: Yes No IMMUNIZATIONS: (i.e. Hepatitis B) EMPLOYER: WORK PHONE: EMPLOYER WILL ALLOW RESPONSE TO CALLOUTS DURING WORK? Yes No IN CASE OF ACCIDENT CALL: NAME: PHONE 1 #: PHONE 2 #: (Life Insurance Beneficiary) NAME: PHONE 1 #: PHONE 2 #: NAME: PHONE 1 #: PHONE 2 #:

2 GENERAL CONDITIONS 1) You must live in the Gibsons & District Fire Protection District and be at least 19 years of age. 2) You must have and maintain a valid BC driver s license; the Drivers Abstract form must be submitted to ICBC. 3) The Criminal Records Disclosure forms must be submitted to the RCMP. 4) You must have a licensed/insured vehicle to respond to all incidents. 5) The decision to accept or reject your application will be the responsibility of the fire department officer group. 6) Your acceptance to a probationary position will be conditional upon receipt of a medical approval from your doctor. We will provide the form and reimburse you for any expenses incurred. A doctor s approval will be required every one to five years. 7) The probationary period will be for a minimum period of 6 months following which there will be an evaluation of your fire fighting knowledge, department procedures and attendance. The officer group may extend the probationary period depending upon the outcome of the evaluation. 8) If you do not already have an air brake ticket you will be provided the opportunity to obtain one. The air brake course must be taken in addition to the regular Wednesday night training sessions. The cost of the training course will be paid by the fire department. 9) Training sessions are each Wednesday night except for statutory holidays. Training begins at 7:30 pm and normally ends at 9:30 pm. In addition to attending a minimum of 66% of the Wednesday night sessions you may be required to attend other training sessions, work parties, and other department functions organized by the department. A practice training stipend will be paid quarterly; you will be considered absent if you arrive more than ½ hour after practice has commenced. 10) If you are unable to attend any training session you are required to phone the training officer. 11) Failure to meet or follow any of the above conditions may necessitate your dismissal from the department. 12) You must pass a physical fitness aptitude test to be considered for membership. I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION SIGNED: FOR OFFICE USE: DOCTOR S APPROVAL RECEIVED YES NO DRIVER S ABSTRACT RECEIVED YES NO CRIMINAL RECORDS CHECK RECEIVED YES NO COPY OF DEPARTMENT CONSTITUTION ISSUED YES NO DEPARTMENT OPERATIONAL GUIDELINES REVIEWED YES NO ACCEPTED/REJECTED BY THE GENERAL MEMBERSHIP YES NO ACCEPTED/REJECTED BY THE OFFICER GROUP YES NO

3 Gibsons & District Volunteer Fire Department Firefighter Medical Examination Surname: Given Names: Date of Birth: / / Year Month Day The medical examination to be performed is to determine if the person above has maintained an acceptable level of fitness to perform as a Firefighter and has not contracted any disabling disease or disability that would prevent him/her from functioning effectively on the fire ground. Worksafe BC Regulation Part 31, section Fitness to use Self Contained Breathing Apparatus (SCBA) A physician s certificate of fitness to use SCBA must be provided to the employer by a firefighter who: a) Experiences breathing difficulty while using the apparatus, or b) Is known to have heart disease, impaired pulmonary function, or any other condition that might make it dangerous for the firefighter to use self-contained breathing apparatus. The physician shall determine using any testing procedures that they feel necessary, if the above named person is fit under the listed criteria below for firefighting duties. This is done to help ensure that the firefighter will not jeopardize themselves or others that they may come into contact with while performing their duties. FIT FOR FULL DUTY: Able to respond to emergency incidents and enter into an atmosphere that is IMMEDIATELY DANGEROUS TO LIFE and HEALTH (IDLH) and fit to wear SCBA as per Worksafe Part 31,Section FIT FOR LIGHT DUTY: Able to respond to emergency incidents, take a support role and be able to drive fire apparatus. The firefighter is not able to enter in to an IDLH atmosphere and is not allowed to wear SCBA as per Worksafe BC Part 31, Section UNFIT FOR DUTY: Not able to respond to emergency incidents, but able to help out around the fire hall as the department sees fit. The firefighter is not able to enter into an IDLH atmosphere and is not allowed to wear SCBA. Page 1 of 3

4 1. If a fee is applicable for the service of the physician it is to be billed to the Gibsons & District Volunteer Fire Department, P.O. Box 8 Gibsons, BC V0N 1V0. 2. To function safely and effectively as a member of the fire department, it is essential that the applicant be physically and mentally fit to perform the varied duties of a firefighter. 3. Blood Pressure / Pulse 4. History of significant previous illness that may affect firefighting duties: 5. Are there any reasons to be concerned that the applicant can safely operate a fire apparatus under stressful situations? Yes / No 6. Is the patient taking any regular medication which may affect duties? Yes / No If yes, please specify: 7. In light of your examination please recommend a frequency that you would like to see this patient again for a follow up examination and revaluation. Every year: Every 3 years: Every 5 years: Page 2 of 3

5 DO YOU CONSIDER THE PATIENT PHYSICALLY AND MENTALLY CAPABLE OF PERFORMING THE DUTIES OF A FIREFIGHTER? CIRCLE ONE: FIT FOR FULL DUTY FIT FOR LIGHT DUTY UNFIT FOR DUTY Physician (signature) Date: Physician Name (print) Address Phone Number Cell address Fax THIS INFORMATION AND ALL OTHER PERSONAL INFORMATION THAT IS GATHERED IS KEPT IN THE STRICTEST OF CONFIDENCE AND USED SOLELY FOR ITS INTENDED PURPOSE. PLEASE RETURN COMPLETED FORM AND INVOICE IF ANY TO: ROB MICHAEL FIRE CHIEF GIBSONS & DISTRICT VOLUNTEER FIRE DEPARTMENT BOX 8, GIBSONS BC V0N 1V0 Page 3 of 3

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