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Fire/EMS Volunteer Application

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This form has been modified since it was saved. Please review all fields before submitting.

Steps

1. Step One This section is complete This section is incomplete
2. Volunteer Garment Fitting Information This section is complete This section is incomplete
3. Medical Information This section is complete This section is incomplete
4. Beneficiary Information This section is complete This section is incomplete
5. References This section is complete This section is incomplete
6. Training & Certifications This section is complete This section is incomplete
7. Experience This section is complete This section is incomplete

Step One

Due to COVID-19 and staffing levels, we cannot accept any volunteers at this time that do not have any current certifications.
This is the Havelock Fire, Rescue and EMS Volunteer application. We are honored that you would like to be a part of this amazing organization. We can't wait to see you in action! Please, fill out as many of the fields as possible and all of the required fields with RED DOTS.
If you have questions, look at the descriptions and/or contact our Fire Department staff at 252-444-6443.
Position Requested*
1. Fire
2. EMS
3. Both Fire and EMS
What volunteer position(s) are you applying for?
First Name*
Middle Name*
Last Name*
Date of Birth*
Date of Birth
Applicant Address
Street Address*
Address Line 2
City*
State*
Zip Code*
Home Phone*
Mobile Phone*
Email*
Confirm Email*
Marital Status*
1. Married
2. Single
Continue

Volunteer Garment Fitting Information

The information submitted for the rest of this section is used to complete the Fire/EMS reporting systems that are utilized by the Havelock Fire Rescue Department. None of this information is shared with a third party. All of this information will remain in your personnel record.
Enter your correct information into the following fields. Havelock Fire and Rescue will use this information to order uniforms and other safety equipment if you are selected.
Volunteer Height
Volunteer Weight
Enter your weight here in pounds.
Gender
1. Male
2. Female
Ethnicity (Optional)
Optional field for reporting purposes
Eye Color
Optional field for reporting purposes.
Hair Color
Optional field for reporting purposes.
Waist Size
Enter your waist size in inches. Example: 30 or 36
Inseam Length
Enter your inseam in inches. Example: 30 or 32
How to measure your inseam: Measure from the lowest part of a pant zipper to the lowest part of your pant or cuff.
Shirt Size
1. X-Small
2. Small
3. Medium
4. Large
1. XL
2. 2XL
3. 3XL
Coat Size
1. X-Small 34 to 36 / CM 81 to 86
2. Small 34 to 36 / CM 86 to 91
3. Medium 38 to 40 / CM 96 to 101
4. Large 40 to 42 / CM 101 to 106
5. XL 42 to 44 / CM 106 to 111
6. 2XL 44 to 46 / CM 111 to 118
7. 3XL 46 to 48 / CM 118 to 122
Check your appropriate coat size. First set of numbers are the coat length and the second set is the chest measurement.
Shoe Size
Enter shoe size, such as 8.5, 10 or 13.5
Continue |Go Back

Medical Information

Primary Physician's Name
First Name
Last Name
Blood Type
1. A+
2. A-
3. B+
4. B-
1. AB+
2. AB-
3. O+
4. O-
Enter any allergies that you may have:
Continue |Go Back

Beneficiary Information

Primary Beneficiary Name
First Name*
Last Name*
Primary Beneficiary Date of Birth
Primary Beneficiary Date of Birth
Primary Beneficiary Relationship
1. Spouse
2. Child
3. Parent
1. Grandparent
2. Legal Trust or Entity
3. Other
If Other:
Primary Beneficiary Address
Street Address*
Street Address Line 2
City*
State*
Zip Code*
Primary Beneficiary Phone*
Contingent 1 Beneficiary Name
First Name
Last Name
Contingent 1 Beneficiary Date of Birth
Contingent 1 Beneficiary Date of Birth
Contingent 1 Beneficiary Relationship
1. Souse
2. Child
3. Parent
4. Grandparent
5. Legal Trust or Entity
6. Other
If other:
Contingent 1 Beneficiary Percentage
Please enter a value between 0 and 100.
Contingent 2 Beneficiary Name
First Name
Last Name
Contingent 2 Beneficiary Date of Birth
Contingent 2 Beneficiary Date of Birth
Contingent 2 Beneficiary Relationship
1. Spouse
2. Child
3. Parent
4. Grandparent
5. Legal Trust or Entity
6. Other
If other:
Contingent 2 Beneficiary Percentage
Please enter a value between 0 and 100.
The total from all beneficiaries must equal 100%.
Continue |Go Back

References

Reference 1 Name
First Name*
Last Name*
Reference 1 Phone*
Reference 2 Name
First Name*
Last Name*
Reference 2 Phone*
Reference 3 Name
First Name*
Last Name*
Reference 3 Phone
Continue |Go Back

Training & Certifications

List all training and certifications that you have completed.
Completed Training
Completed Certifications
Example: ACLS, RN, CCEMTP, EMT
Continue |Go Back

Experience

Experience 1 Name
Enter Agency or Department Name
Experience 1 Address
Address
Address Line 2
City
State
Zip Code
Experience 1 Supervisor Name
First Name
Last Name
Experience 2 Name
Enter Agency or Department Name
Experience 2 Address
Address
Address Line 2
City
State
Zip Code
Experience 2 Supervisor Name
First Name
Last Name

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
Submit | Go Back

* indicates a required field

Submit a Concern

Submit Police Tip

Volunteer For Committee

Contact Us

City of Havelock

PO Box 368

Havelock, NC 28532

Phone: 252-444-6400

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