Arbutus Volunteer Fire Department

Arbutus Volunteer Fire Department

Application for Live-in Program

Name: ______

Current Address: ______

StreetCityStateZip code

Phone number and email address: ______

Date of Birth: ______

Date of membership in the department: ______

Activity involvement i.e. fundraising, duty crew, etc: ______

Certifications: ______

Current Clearance Status, i.e. Observer, Firefighter, EMT, Driver, etc:

Utility: ______

Medic: ______

Squad: ______

Engine: ______

Swift water Rescue: ______

If accepted into the Live-in Program I agree to abide by all polices as outlined in the Arbutus Volunteer Fire Department, Bylaws, Membership Handbook, Live-in Program guide, and any additional polices enacted by the membership or Board of Directors. I furthermore agree to a review of my status in the program on at least a quarterly basis.

Date of Application: ______

Signature of Applicant: ______

Arbutus Volunteer Fire Department

Live-in Program Housing Agreement

This Agreement provides the undersigned the privilege to reside in the dormitories for the period indicated, and commits the undersigned to all terms stated within this agreement.

The undersign agrees to abide by the Arbutus Volunteer Fire Department (AVFD) Bylaws, Polices as outlined in the Membership Handbook, and all other polices which may be enacted by the membership, Captain, President, or Board of Directors. In addition the undersign agrees to abide by all rules and regulations of the Baltimore County Fire Department and the Baltimore County Volunteer Fireman’s Association.

The undersigned agrees to properly perform the duties and responsibilities of a member of the AVFD Live-In Program (LIP) in return for housing assigned within the station.

The undersigned agrees to promptly vacate the dormitory at the expiration of the period of the Agreement, when no longer qualified by the rules/polices, or when so required by disciplinary action or emergency conditions. The undersign agrees to return all fire department and dormitory furnishings and materials in proper condition at the end of the residency period. The undersigned may voluntarily end this Agreement only by written notice fixing an acceptable date to vacate the dormitory.

I acknowledge that if expelled from the LIP I shall vacate the room within seven days from date of notification.

I acknowledge that any and all fees paid to the AVFD as part of the LIPare non-refundable.

The Period of Residency is from ______to ______.

I have read the above, understand it’s meaning, and hereby agree to all terms and conditions stated in the Agreement and contained in the referenced documents.

Live-In Name: ______

Live-In Signature: ______Date: ______

Captain’s Name: ______

Captain’s Signature: ______Date: ______

President’s Name: ______

President’s Signature: ______Date: ______

Arbutus Volunteer Fire Department

Live-in Program Inspection Sheet

Proof of Insurance provided: Yes No

Walls (indicated any significant dents, water marks, etc): ______

______

Carpet (indicate any stains, tears, etc): ______

______

Bed (indicate condition of the mattress, pillow, drawers pull out even, split wood, etc): _

______

Closet (indicate any splits, chips, cracks, stains, etc): ______

______

Doors in working order: ______
Drawers pull out even: ______

Windows (indicate any splits, cracked glass, wood stains, loose ledge, etc): ______

______

Glass clean: ______
Window open and close: ______

Lights work: Yes No

Door Lock functional: Yes No

Volume control and speaker operational: Yes No

Provided key to room: Yes No

Any other damage not covered above: ______

______

Dormitory Room Number: ______Date of Inspection: ______

LIP Advisory Group representative: ______

NameSignature

House Lieutenant: ______

NameSignature

Live-In: ______

NameSignature

LOSAP #: ______Month: ______Year: ______SSN: _____-____-______
Last Name: ______First Name: ______MI: _____
Street Address: ______City: ______
State: ______Zipcode: ______
Fire Calls/Standbys: ______/______EMS Calls/Standbys: ______/______Total: ______/______
Company Committee Meetings and County/State Association Meetings
Date / Time / Description / Date / Time / Description
Formal Training and Classes (EMT, Firefighter, Rescue Tech, etc)
Date / Time / Description / Date / Time / Description
Company Drills and Training
Date / Time / Description / Date / Time / Description
Sleep-ins (indicate actual time)
Date / Time / Date / Time / Date / Time / Date / Time
Standbys (indicate actual time and it must be at least 4 consecutive hours long)
Date / Time / Date / Time / Date / Time / Date / Time / Date / Time
Other Activities (fundraising, details, PFSE, etc)
Date / Time / Description / Date / Time / Description