| Today’s Date:
|
|
04/13/2026 1657 |
| Applicants Name:
|
 |
|
| Age:
|
|
|
| Birth Date:
|
|
|
| Drivers License Number and State (if you drive):
|
|
|
| Home Address:
|
|
|
| Home Phone:
|
|
|
| Email Address:
|
|
|
| Alternate Address (if needed):
|
|
|
| Alternate Phone:
|
|
|
| Current School:
|
|
|
| Grade Level:
|
|
|
| Are your grades usually “C’s” or better: |
|
Yes
No
|
| Please attach a copy of your most recent report card:
|
|
|
| Have you ever been a member of the Hershey Fire Crew: |
|
No
Yes
|
| Are you related to a member of the Hershey Fire Crew: |
|
No
Yes
|
| If you are related to a member of the Hershey Fire Crew, Who:
|
|
|
| Work Permit Number:
|
|
|
| Date Issued:
|
|
|
| Issued by:
|
|
|
| Please attach a copy of your work permit or application. You can get an application at the high school career office:
|
|
|
| Parent, Guardian or Sponsor Name:
|
|
|
| Parent, Guardian or Sponsor Phone:
|
|
|
| Emergency Contact Name:
|
|
|
| Emergency Contact Phone Number:
|
|
|
| Emergency Contact Relation:
|
|
|
| What experience do you have related to the fire service:
|
|
|
| Are you able to attend meeting and training on a regular basis (most are Monday nights from 6-9pm): |
|
No
Yes
|
| Do you have any limitations (physical, mental or otherwise) that could prevent you from performing the duties of a Junior Firefighter: |
|
No
Yes
|
| If you have any limitations, please explain:
|
|
|
| List any accommodations or adaptations you might need to perform your duties:
|
|
|
| Are you a dependable, trustworthy person, who can follow directions without hesitation: |
|
No
Yes
|
| If you are not a dependable, trustworthy person, who can follow directions without hesitation, please explain:
|
|
|
| Are you willing and able to follow rules and regulations of the fire department, local, state or federal laws: |
|
No
Yes
|
| List any illicit drugs, alcohol or prescription you take:
|
|
|
|
| Work History |
|
| Current Employer:
|
|
|
| Current Employer Address:
|
|
|
| Current Employer Phone:
|
|
|
| Your position/title/duties:
|
|
|
| Supervisor Name/Title:
|
|
|
| May we contact your employer: |
|
No
Yes
|
| How many hours per week do you usually work when school is in session:
|
|
|
| When school is not in session:
|
|
|
|
| Note: Child Labor Laws may limit your availability to be active in the department or your paid job |
|
| List any other work history:
|
|
|
| Have you ever been in trouble with law enforcement or school officials: |
|
No
yes
|
| If you have you ever been in trouble with law enforcement or school officials, please explain:
|
|
|
|
| REFERENCES |
|
| Name of Friend, Co-worker, Friend of family, etc.:
|
|
|
| Reference #1 Name:
|
|
|
| Reference #1 Phone Number:
|
|
|
| Reference #1 Email Address:
|
|
|
| Reference #1 - Best time to get a hold of them:
|
|
|
| Name of Teacher, school official, religious leader, etc.:
|
|
|
| Reference #2 Phone Number:
|
|
|
| Reference #2 email:
|
|
|
| Reference #2 Best time to get a hold of them:
|
|
|
|
| Read the Junior Fire Program expectations and rules at www.hersheyfire.org |
|
| Junior Applicants Electronic Signature:
|
|
|
| Date Signed:
|
|
04/13/2026 1657 |
| Parent or guardian electronic signature permission to participate:
|
|
|
| Date Parent or guardian electronic signature signed:
|
|
04/13/2026 1657 |
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.
|
