West Reading Fire Department

Junior Brigade Application

(Please attach $5.00 non-refundable fee for processing and first year's membership dues if approved.)

Name of Applicant: ____________________________________________ Date:_______________

Address:_____________________________________________________________________________

Phone:________________________________ Date of Birth:_____________________________

Height:_______________ Weight:________________

Referred By (name of current member, or put "web site"):________________________________

Are you now, or have you ever been a member of any other fire company junior brigade?________________

If so, give the names of the companies:_______________________________________________________

List any physical restrictions:______________________________________________________________

In case of emergency, notify: Name:_______________________________ Phone:_____________________

Address:____________________________________________________________________________

Name of school you attend:_______________________________________________ Grade:_____________________

Signature of parent or legal guardian is required to join the Junior Brigade.

Signature:_____________________________________ Name:_________________________________

Relationship:__________________ Phone:_________________________________________________

Address:__________________________________________________________________________

I authorize the investigation of all statements on this application. All answers are true and correct to the best of my knowledge.

Signature of Applicant:________________________________________ Date:____________________

I, the above signed applicant, have read and understand the governing rules and will abide by them so long as I am a Junior Brigade Member.

Signature of Applicant:____________________________ Date:_____________ Witness:_______________

DO NOT WRITE BELOW THIS LINE-------------------------------------------------------------------------------------------

Interview by Fire Chief: Comments:___________________________________________________________

_____________________________________________________________________________________

Signature of Fire Chief:________________________________________ Date:_______________________