Cadet Program Application Form
Explorers Receive Training, Respect &
Appreciation
Nature of Work
Cadets receive training on basic Fire
Rescue operations. Cadets may have the opportunity to demonstrate their learned
skills while competing against other Cadet Programs throughout the county,
state and/or nation during training seminars. Upon successful completion of the
Cadet’s Academy, eight hours in the
Requirements and Necessary Documents
To participate in the Cadet Program at the North
Lauderdale Fire Rescue Division, all candidates must:
1. Be at least 14 years of age
(entering 9th grade), thru 18 years-of-age
2. Be a
United States Citizen or lawful resident alien.
3. Must have proof of active
enrollment in school and maintain a 2.0 or higher GPA while in the
Program.
4. Be drug (illegal) free, including
alcohol and tobacco.
5. Have good moral character as
determined by a background check and must not have a criminal or gang
background or involvement.
6. Provide a copy of his/her birth
certificate, photo ID (driver’s license if applicable) and a copy of
their parents/guardians driver’s license.
7. Have and give a 100% commitment
to attended mandatory weekly meetings and assigned details (at least two details
a month).
8. Have 100% support
from parents/guardians.
In addition, all candidates should
provide a copy of their health insurance card/information, and should have a
career interest in the Fire Rescue system and/or a community service-related
field.
Closing Date
Open until positions are filled
How To Apply
Applications may
be obtained at Either Fire Stations:
Station 44
Station 34
Questions?
Contact the NLFR
Cadet Program by calling FF/PM, Andrew Hardesty Lead Instructor, at (954) 270-2326.
The city of
Cadet Program Application Form
Please type or print
clearly. Do not leave any field blank. Enter “n/a” if not applicable.
Last name
___________________________
First name Middle
name______________________________
Date of birth and
age______/______/_______ age_____
Social Security number Date
of application__ __ __- __ __ -__ __ __ __
Mailing
address___________________________
___________________________
City and state Zip Code____________________ ,____ __ __ __ __ __
Home phone number (w/ area
code) (__ __ __) __ __ __ -- __ __ __ __
Work phone number (w/ area
code) (__ __ __) __ __ __-- __ __ __ __
Cellular / pager number (w/ area code) ( __ __ __ ) __ __
__-- __ __ __ __
E- mail
address
_________________________________
Place of birth (county,
state and country) ___________________, ____, __________________
Race Sex Height (feet’,
inches”) ___________,
_______, _______
Weight _______ lbs
Eye color Hair color
______________ / ______________
List any scars, marks or tattoos _____________________________________________________________________
By signing this document, I
certify that all of the information on this entire application is true and
complete to the best of my knowledge. I understand that all information is
subject to investigation and that removal of my name from consideration or
dismissal from service. I understand that the City of
I understand that this
application is the property of the City of
Cadet Signature_________________
Parent or Guardian Signature
_______________________________
INSTRUCTIONSTO APPLICANTS 1. Print clearly
or type information 2. Answer every
question (Do not refer to resume). 3. If a question is
not applicable, mark n/a. 4. All are
statements subject to verification. AN EQUAL It
is the policy of the City of
READ CAREFULLY
Cadet Program Application Form
Parental & Emergency Information
Parent / guardian
Father’s / Guardian’s name:_____________________
Home address_________________________
City, state, zip code_________________________
Home phone (w/ area code) _________________________
Work phone (w/ area code) _________________________
Cell phone or pager (w/ area code) _________________________
Mother’s /
Guardian’s name: _________________________
Home address_________________________
City, state, zip code_________________________
Home phone (w/ area code) _________________________
Work phone (w/ area code) _________________________
Cell phone or pager (w/ area code) _________________________
Emergency Contact
Information
In the event of an emergency and the parent/guardian is
unavailable, please list two individuals to be contacted:
Contact #1 Name _________________________
Home address_________________________
City, state, zip code_________________________
Home phone (w/ area code) _________________________
Work phone (w/ area code) _________________________
Cell phone or pager (w/ area code) _________________________
Mother’s /
Guardian’s name: _________________________
Home address_________________________
City, state, zip code_________________________
Home phone (w/ area code) _________________________
Work phone (w/ area code) _________________________
Cadet Program Application Form
Last name
First name Middle name
Date of birth
Social Security number Race
Sex
Home address
City and state Zip Code
Medical Information
Health / Accident Insurance
Company
Phone (w/ area code) Policy
Number
Are you now, or have you
ever been, subject to (please answer yes or no):
Asthma __________ Fainting Spells
__________ Convulsions __________
Diabetes __________ Heart
Trouble __________ Bleeding Disorders __________
Allergy(ies) to any medication, food,
plant, insect bite or other material or substance ___________
If you answered yes to any
of the above, please list the allergies:
Do you have any condition
that may require special care, medication, or diet? [ ] yes [ ] no
If you answered yes to the
above, please explain:
Are you taking any
medication? [ ] yes [ ] no
If you answered yes to the
above, please explain:
Are there any restrictions
placed on you for any reason, including medical? [ ] yes [ ] no
If you answered yes to the
above, please explain:
Cadet Program Application Form
Applicant’s / Parental Authorization
for Medical Treatment
This medical history is correct so
far as I know, and the person herein described has permission to Engage in all
prescribed activities, except as noted by me. In the event I cannot be reached
in an Emergency, I hereby give permission to medical personnel and/or
physician, selected by the adult leader in charge, to treat my son/daughter
(listed applicant) for any medical or surgical emergency as deemed necessary by
medical personnel and/or physician.
Applicant’s name (print) _________________________
Signature Date________________/_________
Parent / guardian name_________________________
Signature Date________________/_________
Home phone (w/ area code)
( )_____-_______
Work phone (w/ area code) ( )_____-_______
Cell / pager (w/ area code) (
)_____-_______
I solemnly swear and affirm that the
answers that I have made to each and all of the questions are true and complete
to the best of my knowledge and belief. I agree and understand that any
misstatements of material facts contained herein will be cause for forfeiture on my part to all rights to membership in the North Lauderdale Fire Rescue
Cadet Program
I hereby authorize the North
Lauderdale Fire Rescue Office to verify any and all facts listed on
this application, and to contact any references I have listed.
Date: ___/___/___
Signature of applicant:
_____________________
Signature of parent /
guardian______________________
As the parent/guardian of the minor
child applying for membership to the North Lauderdale Fire Rescue Cadet
Program
, I hereby give my permission for my
child to become a member of the North Lauderdale Fire Rescue Cadet
Program
Date
Signature
of parent / guardian
Driver’s
license number
Issuing
state
STATE OF
) SS
On this ___________________________
day of ______________________________, 20___________,
Before me personally appeared
_________________________________________________________
to me well know to be
the same person described in and who executed the foregoing document, who
having been duty sworn/or affirmed before me, stated that to the best of their knowledge
and belief that the statements and answers to the questions in foregoing
questionnaire contained, whether in writing or in
print, are true.
___________________________________________
NOTARY PUBLIC, STATE OF
REQUEST FOR PERMISSION TO RIDE AS A
CADET
AND HOLD HARMLESS/INDEMNIFICATIONAGREEMENT
I, _____________________________,
being 18 years of age or older, do hereby request permission from the North Lauderdale Fire
Rescue (hereinafter
referred to as "NLFR") for my minor child,
a NLFR Cadet, to ride in an authorized NLFR vehicle and participate in NLFR
CADET functions, subject to the following conditions:
If permission is
granted, my minor child will obey all instructions, orders, or commands
given to my minor child by any NLFR employee during
the ride or such functions. I understand that such instructions, orders, and
commands will be for my minor child's safety and protection.
I am fully aware of and appreciate
the fact that, as a CADET, minor child may experience or encounter many of the
dangers associated with Fire Rescue work including, but not limited to, vehicle
accidents, structure fires, and emergency medical situations. I fully realize
and appreciate the fact 'that such dangers may result
in physical harm, injury, or death to my minor child. I, on
behalf of my minor child, myself, my minor child's heirs, executors and
administrators, voluntarily accept any or all risks associated with this
activity, and agree to hold harmless and indemnify NLFR, the City of
North Lauderdale, or its commissioners, directors, City Manager, Fire Chiefs,
Fire officers and all other NLFR employees, agents,
representatives, volunteers or servants from any claim, cause of action, or
lawsuit resulting from personal injury or property damage to my minor child or
others during my minor child's ride participation as an Cadet including any claim, cause of action or
lawsuit based on the negligence, actions or inactions of NLFR,
the City of North Lauderdale, or its commissioners, directors, City Manager,
Fire Chiefs, Fire officers and all other NLFR
employees, agents, representatives, volunteers or servants.
I, the
undersigned, intending to be legally bound hereby, for my minor child,
myself, my minor child's heirs,
executors, and administrators, waive and release any and all rights and claims
for losses and damages including, but not limited to, personal injuries and
property damage, that exist now or in the future, against NLFR,
the City of North Lauderdale, or its commissioners, directors, City Manager,
Fire Chiefs, Fire officers and all other NLFR
employees, agents, representatives, volunteers or servants resulting,
either directly or indirectly, from my minor child participating as a NLFR Cadet including
any claim, cause of action or lawsuit based on the negligence, actions or
inactions of NLFR,
the City of North Lauderdale, or its commissioners, directors, City Manager,
Fire Chiefs, Fire officers and all other NLFR
employees, agents, representatives, volunteers or servants
I understand that
this Hold Harmless and Indemnity Agreement includes any and all claims based on
the negligence, actions or inactions of NLFR, the
City of North Lauderdale, or its commissioners, directors, City Manager, Fire
Chiefs, Fire officers and all other NLFR employees,
agents, representatives, volunteers or servants and covers bodily injury
and property damage, whether suffered by my minor child or another person.
The parties recognize that in order
to simplify the paperwork associated with each Cadet detail,
function, special event, or trip, this agreement shall be applicable to all
Cadet Activities.
It is further
agreed that as a Cadet my minor child will not carry a firearm or any
other weapon while on duty.
In entering this
Agreement, the parties represent that they have had a reasonable opportunity to
seek and select legal advice and have relied upon the advice of their own legal
representative, who is an attorney of their own choice, or have voluntarily
chosen not to seek the advice of an attorney, and that the terms of this
Agreement have been completely read and that those terms are fully understood
and are voluntarily accepted. In the event of litigation in connection with or concerning
the subject matter of this Agreement, the prevailing party shall be entitled to
recover all costs and expenses incurred by such party in connection therewith,
including reasonable attorney's fees.
Printed Name of Parent or Guardian
_____________________________
Signature of Parent or Guardian
_____________________________
Date_________
__________________________
__________________________ zip ___________
( ) _______--___________
Name of NLFR
CADET
STATE OF
The foregoing instrument was acknowledged before me this _______day of__________,
20__,
by______________________________ who
is personally known to me or who has produced
________________________________ as identification.
________________________________
Notary Public
________________________________
Typed/Printed Name of Notary