| Today’s Date:
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12/02/2024 0910 |
| Applicants Name:
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| Age:
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| Birth Date:
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| Drivers License Number and State (if you drive):
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| Home Address:
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| Home Phone:
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| Email Address:
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| Alternate Address (if needed):
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| Alternate Phone:
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| Current School:
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| Grade Level:
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| Are your grades usually “C’s” or better: |
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Yes
No
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| Please attach a copy of your most recent report card:
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| Have you ever been a member of the Hershey Fire Crew: |
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No
Yes
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| Are you related to a member of the Hershey Fire Crew: |
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No
Yes
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| If you are related to a member of the Hershey Fire Crew, Who:
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| Work Permit Number:
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| Date Issued:
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| Issued by:
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| Please attach a copy of your work permit or application. You can get an application at the high school career office:
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| Parent, Guardian or Sponsor Name:
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| Parent, Guardian or Sponsor Phone:
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| Emergency Contact Name:
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| Emergency Contact Phone Number:
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| Emergency Contact Relation:
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| What experience do you have related to the fire service:
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| Are you able to attend meeting and training on a regular basis (most are Monday nights from 6-9pm): |
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No
Yes
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| Do you have any limitations (physical, mental or otherwise) that could prevent you from performing the duties of a Junior Firefighter: |
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No
Yes
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| If you have any limitations, please explain:
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| List any accommodations or adaptations you might need to perform your duties:
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| Are you a dependable, trustworthy person, who can follow directions without hesitation: |
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No
Yes
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| If you are not a dependable, trustworthy person, who can follow directions without hesitation, please explain:
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| Are you willing and able to follow rules and regulations of the fire department, local, state or federal laws: |
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No
Yes
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| List any illicit drugs, alcohol or prescription you take:
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| Work History |
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| Current Employer:
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| Current Employer Address:
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| Current Employer Phone:
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| Your position/title/duties:
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| Supervisor Name/Title:
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| May we contact your employer: |
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No
Yes
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| How many hours per week do you usually work when school is in session:
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| When school is not in session:
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| Note: Child Labor Laws may limit your availability to be active in the department or your paid job |
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| List any other work history:
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| Have you ever been in trouble with law enforcement or school officials: |
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No
yes
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| If you have you ever been in trouble with law enforcement or school officials, please explain:
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| REFERENCES |
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| Name of Friend, Co-worker, Friend of family, etc.:
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| Reference #1 Name:
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| Reference #1 Phone Number:
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| Reference #1 Email Address:
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| Reference #1 - Best time to get a hold of them:
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| Name of Teacher, school official, religious leader, etc.:
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| Reference #2 Phone Number:
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| Reference #2 email:
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| Reference #2 Best time to get a hold of them:
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| Read the Junior Fire Program expectations and rules at www.hersheyfire.org |
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| Junior Applicants Electronic Signature:
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| Date Signed:
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12/02/2024 0910 |
| Parent or guardian electronic signature permission to participate:
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| Date Parent or guardian electronic signature signed:
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12/02/2024 0910 |
By siging my electrtonic signiture above I do hereby promise to adhere and abide by the rules and regulations set-forth by Pennsylvania Child Labor Laws, Hershey Fire Company and Junior Program Guidelines. I understand that it is the right of the Hershey Fire Company to terminate this program at any time for any reason. Upon my termination (voluntary or involuntary), I will surrender all issued equipment in a timely manner.
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