Membership Application

Membership Application

Please complete the form below and a member of our team will be in touch.

Step 1 of 6

Section I
Membership Classification*
- Regular (Fire or Fire/EMS)
- EMS Only
- Administrative
- Associate
- Junior
Name*
First Middle Last
Address*
Street Address City State ZIP Code
Phone*
Date of Birth*
MM slash DD slash YYYY
Email*
Enter Email Confirm Email
Sex*
Race*

Section II
Occupation
Employer's Name
Employer's Address
Street Address City State ZIP Code
Employer's Phone
Medical Conditions
List any medical conditions that may affect your performance or limit your duties in this Fire Company:
Physician's Name
First Last
Physician's Address
Street Address City State / Province / Region ZIP / Postal Code
Physician's Phone
Emergency Contact Person*
First Last
Emergency Contact Address*
Street Address City State ZIP Code
Emergency Contact Phone*
Relationship*

Section V
Reference #1*
List someone NOT related to you:
First Last
Phone*
Reference #2*
List someone NOT related to you:
First Last
Phone*
Reference #3*
List someone NOT related to you:
First Last
Phone*
Do you have any objection to the Membership Committee verifying any and all statements concerning this application?*
Do you have any objection to the Membership Committee verifying any and all statements concerning this application?
In a brief statement, please explain why you want to become a member of the Church Hill Volunteer Fire Company.*
In a brief statement, please explain why you want to become a member of the Church Hill Volunteer Fire Company.