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?

Do you have a valid driver’s license?

Do you have a car available for use while volunteering?

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.
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Signature of Applicant Date
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Parent/Guardian Signature (required if less than 18 years of age) Date