Rockhill Volunteer Fire Department

2017 Incidents
Jan 27
Feb 30
Mar 29
Apr 29
May 21
Jun 32
Jul 10
Aug 0
Sep 0
Oct 0
Nov 0
Dec 0
Total 178

Past Incidents
2016 666
2015 930
2014 690
2013 381
2012 408
2011 350
2010 280

Web Counters
Website Visitors
Since
July 24, 2014
85,670
Visitors Today
Dec 18, 2017
14

Fillable Membership Application

Rockhill Volunteer Fire Department
Membership Application

Required   Indicates Required Field
General Information
Date Stamp: Required
Transfer from other County Station?: Required Yes
No
What station are you transferring from?:
First Name: Required
Middle Name: Required
Last Name: Required
Date of Birth: Required
Are you 18 or Older: Required Yes
No
Are you a US Citizen?: Required Yes
No
Address: Required
City/State/Zip: Required
Home Phone Number: Required
Cell Phone:
Email : Required
How did you learn of this opportunity to provide volunteer services?:
Emergency Contact Information
Name: Required
Relationship:
Address of Contact: Required
Contact City/State/Zip: Required
Daytime Phone Number: Required
Night Time Phone Number:
Type of Membership Applying For
ASSOCIATE MEMBERSHIP Performs administrative and support roles such as assisting with fundraising, recruitment, and department functions. Attend a minimum of four monthly meetings in a twelve month period.: Associate
OPERATIONAL MEMBERSHIP Responds to emergency incidents, participates in company training, weekly duty crew, fundraisers and department functions. Already has, or has the desire to attain, state certification training. Attend a minimum of four monthly meet: Operational
References
Reference 1 Name: Required
Reference 1 Phone Number: Required
Reference 1 Email:
Reference 2 Name: Required
Reference 2 Phone Number: Required
Reference 2 Email:
Reference 3 Name: Required
Reference 3 Phone Number: Required
Reference 3 Email:
Service Orientation
Are you presently or have you ever been a member of any fire, rescue, EMS or emergency services organization? : Yes
No
IF SO, WHAT AGENCY? :
May we contact your superior officer or supervisor regarding your service? : Yes
No
Supervisor Name:
Supervisor Phone Number:
Have you ever been denied membership, had disciplinary action taken against you, or been asked to resign by any organization or emergency services agency? : Yes
No
If you answered yes, explain in detail. Be sure to include the name and address of the organization::
Qualifications/Skills/Training
List any fire, rescue, EMS and/or emergency management training, experience and certifications you currently hold. Include expiration dates and certifying state, department, or agency. Please attach copies of your certifications to this application.:
List any special qualifications, skills, certificates and/or licenses you hold. Include armed forces training, skills with machines, memberships in professional, scientific or academic societies, work training programs, public speaking experience and tra:
Medical Information
Do you have any medical conditions or physical limitations that should be considered?: Yes
No
Are you currently receiving any special medical treatment or medications?: Yes
No
If you answered YES, please explain: :
Certification and Agreement (This statement must be signed. Please read the following statement carefully before signing.) I hereby certify that the facts set forth in the above Volunteer Membership Applications are true and complete to the best of my kn:
Name of Applicant (This Will serve as a Digital Signature): Required
Date Signed: Required
Parent of Guardian Name (If Under 18):
CRIMINAL HISTORY BACKGROUND AND FINGER PRINTING MUST BE PROVIDED BY THE COUNTY OF STAFFORD, VIRGINIA DURING ANY APPLICATION PROCESS PRIOR TO APPROVAL AND ACCEPTANCE OF THIS APPLICATION.:




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Rockhill Volunteer Fire Department Inc.
2133 Garrisonville Road
Stafford, VA 22556
Emergency Dial 911
Non-Emergency: 540-752-0200
E-mail: info@rockhillvfd.org
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