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East Kentucky Trackers Application

Today’s Date: _______________                            

Personal Information

 

Name:     ______________________________________________________

 

Address: _____________________________       City:_________________ State______   Zip:__________

Home Phone: _________________________       Work Phone: ________________________________

 

Cell Phone: ___________________________       Email: ______________________________________

Why are you interested in volunteering?

Personal interest

Educational Internship

 Community Service Hours

 Advanced Training

Other _________________________

Age:         ____over 18                           ____under 18

Have you ever worked or do you currently work for Kentucky Emergency Management?   Yes   No

Do you have a valid driver’s license?    Yes     No

Do you have a car available for use while volunteering?       Yes      No

 

Emergency Contact Information

Name: ________________________________    Relationship: ___________________________

Address: ______________________________________________________________________

Contact Number(s): _____________________________________________________________

Experience/Training

High School Education: ___________________________________________________________

College Education: _______________________________________________________________

KyEM/Homeland Security Certifications: (y/n)

ICS 100: ___            ICS 200: ___            ICS 300: ___            ICS 400: ___       ICS 700: ___ ICS 800: ___

  BSAR: ___ Basic, Interm. or Advanced: ____________ Years Total: ____

 Man-Tracking: ___ Novice or Experienced: _____________   Years Total: ____

Advanced Man-Tracking: ___ (Years Total) Incident Management Courses:* __________________

*If Yes please list above in the blank space your Course Certifications

 

Are you currently associated with any fire or rescue organization with-in the State of Ky?________ If so who?

Military? Yes          No   Branch? ___________           Years Service? ____               Discharge: _________________

Who is your current employer? ___________________________________________________________

Will your employer allow you to leave to respond to a call?

Yes         No

Will you be able to respond to a call that may result in a stay for an extended period of time?:

                                                                                Yes          No

 

How many times a month are you dedicated to meeting and training?:

     0-1     1-2      2-4      Quarterly                            Not Interested

Quarterly East Kentucky Trackers will be participating in a training exercise which may involve overnight stay, are you willing to participate in such a function.     Yes    No

 

Special Skills

Do you have any other special skills which may be valuable to the East Kentucky Trackers?                                                                                                        Yes     No       (If yes please list below)

Do you speak any other languages?    Yes      No  (If yes please list below)

_______________________________________________________________________

Are you a Member or Employed by any Ky. Law Enforcement Agency?

     Yes                      No                  (If yes please list below)

__________________________________________________________________________

Criminal History

All volunteer positions require a Criminal History check.  Conviction will not necessarily disqualify you from participating.  Have you ever been convicted of a felony?  Yes    No

If yes, explain.

________________________________________________________________________________________________

 

Please describe in 3-5 sentences why you want to be a volunteer at East Kentucky Trackers:

Why, at this particular time in your life have you chosen to volunteer with us?  What do you hope to gain from being a volunteer?

__________________________________________________________________________________________________

East Kentucky Trackers considers applicants for internships/volunteering without regard to sex, race, age, religion, national origin, veteran or marital status, or any other legally protected status.  We provide reasonable accommodation to qualified individuals with disabilities when it would not be an undue hardship.  If you need a reasonable accommodation in the pre-placement process, please contact the Volunteer Manager.

   
  
AUTHORIZATION AND AGREEMENT BY APPLICANT
  1. I certify that the facts set for in this volunteer application are true and complete to the best of my knowledge. I understand that any false statement, omission or misrepresentation in my application or placement interview may result in the rejection of my application or discharge from the volunteer program.
  2. I consent to having East Kentucky Trackers complete a criminal background check prior to volunteering.
  3. I agree to complete all drug screening requirements relevant to the position for which I am applying
  _______________________________________________________  ________________________      Signature of Applicant                                                                                  Date _______________________________________________________  ________________________ Parent/Guardian Signature (required if less than 18 years of age)    Date  
DRUG AND ALCOHOL TESTING CONSENT
  East Kentucky Trackers recognizes the costs to society and to individuals from drug and alcohol use. The Agency maintains a firm commitment to strive to provide reliable service to The Commonwealth of Kentucky  and a safe and healthy work environment for its in volunteers. While the vast majority of volunteers are not involved with alcohol abuse or illegal drugs, those who are can have an adverse impact on the organization, as well as their own safety.  To meet our obligations, and to comply with our obligation under the Drug Free Workplace Act of 1988, the following policy has been adopted and will be enforced: The Agency prohibits the unlawful use, sale, possession, manufacture, distribution, or being under the influence of alcohol, drugs or any controlled substance, on Agency property, in the presence of Agency Members, while on duty, during & responding to emergency calls or training operations, while operating an Agency vehicle or attending an Agency-sponsored event.
  1. Volunteers who violate this prohibition will be subject to disciplinary action, up to and including criminal charges. Nothing in this policy restricts the Agency’s right to terminate a volunteer at any time, with or without notice, for any reason not expressly prohibited by law.
 
  1. The agency retains the right to require any volunteer to report for drug and/or alcohol testing for reasonable suspicion or following an accident in which there is injury to persons or damage to property.
    3.    Volunteers must abide by the terms of this statement and must notify this Agency of any criminal drug conviction within five days of the conviction.     I have read and understand the Drug Free Workplace Compliance Statement. I agree to comply with the East Kentucky Trackers’ Drug and Alcohol Policy. I understand the Zero Tolerance Policy of the East Kentucky Trackers and understand that if found to be under the influence of alcohol or drugs at any Agency Activity that my credentials as a East Kentucky Tracker shall be terminated immediately. _______________________________________________________  ________________________ Signature of Applicant                                                                             Date _______________________________________________________  ________________________ Parent/Guardian Signature (required if less than 18 years of age)  Date