New Member Application Packet Checklist:

o New Member Application Packet Checklist (1 page) o Letter to new applicants (1 page) o Information for Probationary Members (3 pages) o Application for Membership (4 pages) o Family Information Form (1 page) o Designation of Beneficiary Form (1 page) o Hepatitis B Vaccine Consent & Information Form (2 pages) o Volunteer Criminal History Request and Authorization Form (background

check form) (1 page) o Authorization to Obtain / Release Juvenile Records (Junior Division

Applicant background check form) (1 page)

Old Saybrook Fire Company No. 1, Inc. 310 Main Street

Old Saybrook, CT 06475 860-395-3149

 

 

Dear Applicant: Thank you for your interest in becoming a member of the Old Saybrook Fire Company No. 1. There are a few easy steps you need to follow to get the process moving along:

1. Fill out the membership application as well as all the other forms in the packet.

2. Return the completed packet to the Old Saybrook Fire Department, Attn: Training Division.

3. A training officer will contact you to set up an oral interview.

4. After your oral interview, a training officer will clear you to schedule your entry physical. Contact one of our department physicians: Shoreline Medical Associates: (203) 245-4933, 1353 Boston Post Road, Madison.

If you have any questions, contact Capt. Steve Lesko at (860) 876-0806 or via e-mail at training@oldsaybrookfire.com. Good Luck, OSFD Training Division

Old Saybrook Fire Company No. 1, Inc. 310 Main Street

Old Saybrook, CT 06475 860-395-3149

 

Information for Probationary Members

Thank you for your interest in the Old Saybrook Fire Department. We especially welcome applicants with previous fire or emergency medical experience. The purpose of this sheet is to explain the Department’s policies for Probationary Members. All Probationary Members, including those with experience in the fire service, emergency medical services, or public safety, are expected to follow all Department policies and standard operating guidelines that relate to Probationary Members. These include, but are not limited to, the following: Tuesday Nights Tuesday nights are the night each week we expect you to set aside for fire department activities. The first Tuesday night of the month is our Company meeting. The second and fourth Tuesday nights are Probationary Member training. This is when you will receive your fire service training by participating with your fellow “probies” under direct supervision of the Department’s Training Officers. The third Tuesday of the month is Company drill. Three unexcused absences during the probationary period will result in termination of membership. Term of Probation The Department by-laws provide for a minimum probationary period of six months. There is no guarantee that your probationary term will not be longer. All Probationary Members must complete their training matrix before being proposed for Regular Membership. Previous completion of state certifications will count towards your training matrix; however, all Department-specific training must be completed as well. Probation in General The probationary term is, in part, a period for new members to prove themselves and to give the current membership an opportunity to introduce themselves and work alongside the new members. Probationary Members with experience are being evaluated and observed in the same manner as inexperienced Probationary Members. The Regular Members will eventually vote on whether to bring you in as a Regular Member. You are urged to make a good impression, take the initiative, and make sure the Regular Membership has ample reason to believe you would be an asset to the Department.

Old Saybrook Fire Company No. 1, Inc. 310 Main Street

Old Saybrook, CT 06475 860-395-3149

All Probationary Members receive the same level of instruction and are treated equally. If you are coming to us from another Department, please do not take any repetitive instruction that you receive personally. Our goal is to make sure that each new member starts with the same basic knowledge and skills. While we know some new members have experience, it is difficult for us to judge each individual’s level. This is why refreshing the basics with everyone is our preferred method of instruction. Equipment All Probationary Members will be issued personal protective equipment by the Department, and are to use this equipment. This includes helmets: all probationary firefighters are to wear orange probationary shields and orange tetrahedrons on their helmets during their term of probation. There are two reasons for this policy. (1) It enables officers to quickly identify probationary firefighters on the fireground, and (2) as a department, we feel the “black shield” is a symbol of being promoted to regular status and must be earned. If you own your own helmet and wish to use it during your probationary period, it must be outfitted with the probationary shield and tetrahedrons. Fireground Duties As a Probationary Member you will be expected to help out in any capacity necessary on the fireground. Probationary Members are typically responsible for basic tasks such as rolling hose, retrieving equipment, washing trucks after calls and drills, etc. All Probationary Members are expected to complete these tasks. All Probationary Members are expected to seek out things to do during and after calls and drills until all necessary work is completed. SCBA Qualification All Probationary Members must receive the approval of the Training Division before being cleared as an SCBA qualified firefighter in the department. This will typically require satisfactory completion of multiple department SCBA drills. Department Policies and Procedures The Department has its own polices and procedures, which may or may not be similar to those of other area departments. All Department members are expected to follow the policies, procedures, and standard operating guidelines of the Old Saybrook Fire Department. If you have any questions as to these policies, please see a training officer for clarification. Points and Participation As part of your interview and orientation process, the department’s point system will be explained to you. In summary, members receive three points for attending a call, three points for a drill or training class, and one point for a company or committee meeting. Probationary Members are expected to regularly attend drills and meetings and to make as many calls as possible. Your point total will be used to gauge your level of participation in the department. Regular Members are expected to accrue a minimum of 150 points per year, and Probationary Members are held to the same standard. Any

Probationary Member who does not accrue 150 points within a year of joining the Department, or who at any time shows a lack of participation as evidenced by their point total, will be required to meet with the training officers and show cause why they should not be dropped from the Department. Physical Exam ALL applicants must have a full physical examination. This exam must certify the applicant is capable of performing the duties of a firefighter. The physical exam must be given by one of the Department-appointed physicians. The physical exam will be paid for by the Department. The physical exam should NOT be scheduled until the applicant has had his interview with the Training Division. I have read and understand the above. ______________________________________________________________________ Applicant Signature Date

 

APPLICATION FOR MEMBERSHIP I am applying to become a member in the following division (circle one):

PROBATIONARY (REGULAR FIREFIGHTER)

JUNIOR DIVISION SUPPORT DIVISION

NAME: ________________________________________ DATE OF BIRTH: ____________

ADDRESS: ___________________________________________________________________

OWN / RENT / LIVE WITH PARENTS (Circle One)

HOME TELEPHONE # ______________ WORK # ____________ CELL # _____________

EMAIL ADDRESS: ____________________________________________________________

EMPLOYER’S NAME: ________________________________________________________

EMPLOYER’S ADDRESS: _____________________________________________________

EMERGENCY CONTACT NAME: ______________________________________________

ADDRESS FOR EMERGENCY CONTACT: ______________________________________

EMERGENCY CONTACT TELEPHONE # _______________________________________

RELATIONSHIP TO EMERGENCY CONTACT: _________________________________

OSFD SPONSOR: (PRINT) ___________________ (SIGN) ___________________________

OSFD SPONSOR: (PRINT) ___________________ (SIGN) ___________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS

Do you have any previous firefighting or emergency medical training?

YES _____ NO _____

Old Saybrook Fire Company No. 1, Inc. 310 Main Street

Old Saybrook, CT 06475 860-395-3149

 

If “YES”, please explain:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have any fears or phobias which may affect your ability to be a firefighter?

YES _____ NO _____

If “YES”, please explain:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Do you have a valid CT driver’s license? YES _____ NO _____

What hours do you work? _______________________________________________________

Can you leave work for an emergency response? YES ____ NO ____

PROBATIONARY MEMBERS TRAIN EVERY TUESDAY NIGHT. THREE UNEXCUSED ABSENCES DURING THE PROBATIONARY PERIOD WILL RESULT IN TERMINATION OF MEMBERSHIP.

I hearby make application for membership to the Old Saybrook Fire Company No. 1, Inc. I agree to abide by the Company By-Laws and Constitution, Standard Operating Guidelines and Standing Orders.

I hearby certify that the information contained in this application is true to the best of my belief and knowledge.

Permission is given to the Old Saybrook Fire Company No. 1, Inc. to verify any and all information contained in this application.

SIGNATURE: ________________________________________________________________

DATE: _______________________________________________________________________

FOR APPLICANTS TO THE JUNIOR DIVISION

Scholastic achievement is held in the highest regard by the Old Saybrook Fire Company No. 1 membership. School work, school activities and family commitments are expected to be prioritized over Junior Division activities.

Junior Division training is scheduled for the second Tuesday of the month; monthly meetings are held the first Tuesday of the month.

Three unexcused absences from scheduled activities will result in disciplinary action, up to and including termination from membership. Excused absences can be arranged by contacting a Junior Division advisor or Department Chief.

To be completed by the applicant’s parent / guardian:

Do you understand that the applicant will be asked to assist the fire department in limited risk activities? Do you have any reservations in this regard? _________________________ ____________________________________________________________________________________________________________________________________________________________

In your opinion, how well does the applicant handle stressful situations? ________________ ____________________________________________________________________________________________________________________________________________________________

Do you agree to the curfew conditions as explained in the Old Saybrook Fire Company No. 1, Inc. By-Laws and Constitution? ________________________________________________ ____________________________________________________________________________________________________________________________________________________________

I give permission for _____________________ to be a member of the Junior Division of the Old Saybrook Fire Company #1, Inc. I understand that before this application can be accepted I must meet with the advisor(s) to learn exactly what being a Junior Division member entails.

Parent or guardian signature ____________________________________________________

To be completed by the school:

I understand what being a member of the Junior Division of the Old Saybrook Fire Company No. 1, Inc. requires. As a representative of the school, we feel that ____________ is of good moral character and can handle this responsibility along with his or her academic workload and will be an asset to the fire department.

Dean of students signature ______________________________________________________

Name___________________________ Home Phone_____________Blood Type_______ Home Address_______________________________________________________________ Employer Name, Dept, Supervisor, Address & Phone_________________________________________________ ____________________________________________________________________________________________ Your Physicians Name & Phone Numbers__________________________________________________________ Name & Phone number of the religious organization you may be affiliated with_____________________________ ___________________________________________________________________________________________ Spouse/Significant Other_______________________Home Phone_____________Cell Phone__________ Spouse/SO Home Address________________________________________________________ Spouse/SO Employer Name, Dept, Supervisor, Address & Phone_______________________________ ___________________________________________________________________________________________ Closest Relatives other than Spouses Contact Phone Numbers___________________________________________ ____________________________________________________________________________________________ Children Names, Yr’s of Birth, School they attend____________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Children’s Babysitters Phone Number______________________________________________________________ Please list any special needs that you feel your family may require________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

Family Information Form The information contained on this form will be kept confidential and private. It

should be reviewed annually or anytime your aware that a change should be made. Please place in an envelope and drop in the Chiefs Mail Slot. Or Mail it to

Old Saybrook Fire Dept, Training Chief, 310 Main Street, Old Saybrook CT 06475

Date form Filled Out_________________________

Old Saybrook Fire Dept 310 Main Street

Old Saybrook CT 06475 860-395-3149

Designation of Beneficiary Form

Department Name: Old Saybrook Fire Department Member Name:___________________________________________________ Date Joined______________________ Date of Birth_____________________ I hereby designate the following beneficiary (ies) to receive all death benefit proceeds payable under the policy (ies). Primary Beneficiary (ies) Relationship Date of Birth Percent (If under age 18)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________ Contingent Beneficiary (ies) Relationship Date of Birth Percent (If under age 18)

_____________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________ This beneficiary form is for: (If department has policy in force) ( X ) Volunteer Firemen’s Accident Policy ( X ) Group Life Policy ( X ) Accident and Sickness Policy ( X ) 24 Hour Accident Policy _________________________________ Member Signature _________________________________ Date

Important: To be retained by the department for it’s records.

Old Saybrook Fire Dept 310 Main Street

Old Saybrook CT 06475 860-395-3149

Hepatitis B Vaccine Consent & Information form.

Recommended by CDC, Required By OSHA: That all employees with potential exposure to blood and body fluids or tissues are offered the Hepatitis B Vaccine free of charge. Description: Since 1986 Hepatitis B vaccine is synthetically made. It does NOT utilize serum from hepatitis B carriers. Contraindications: It should not be ad-ministered to anyone who is allergic to yeast or Thimerisol. Administration: Requires 3 doses, 1 ml intramuscu-larly. 1st dose: at elected date. 2nd dose 1 month later. 3rd dose 6 months after the first dose. *Note: After com-pleting vaccine series, employees can be tested for the presence of detectable antibodies (immune status). Those who have failed to respond to the vaccine will be given a second series. Not all employers commit to post testing. Side Effects: Soreness at injection site and mild systemic symptoms (fever, fatigue). Protection: Currently, CDC does not recommend a booster. Immunity against the Hepatitis B Virus appears to outlast presence of detectable antibodies. The immunity can persist for greater than 2 years. I have read the information about hepatitis B and it’s vaccine. I have had an opportunity to ask questions and un-derstand the benefits and risks of the Hepatitis B vaccination. I understand that I must have three doses to develop immunity. However, as with all medical treatments, there is no guarantee that I will become immune or that I will not experience any adverse side effects from the vaccine. Name_______________________________________________ Date _________________________ Old Saybrook Fire Department SS#__________________________________________________

Status of Hepatitis B Vaccine

_______ I have already received the Hepatitis B Vaccine Series _______ I request that the Hepatitis B Vaccine be given to me. Employee’s Signature _________________________________________ Date__________________ Employee under 18 Parent/Guardian Printed Name___________________________________________ Employee under 18 Parent/Guardian Signature____________________________ Date______________ I have been offered the Hepatitis B Vaccine and do NOT wish to receive it. I understand that due to my potential occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine at no charge to myself. However, I decline the Hepatitis B vaccination at this time. I understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with the Hepatitis B vac-cine, I can receive the vaccination series at no charge to me. Employee’s Signature _________________________________________ Date__________________ Employee under 18 Parent/Guardian Printed Name___________________________________________ Employee under 18 Parent/Guardian Signature____________________________ Date______________

First Dose

Date_____________________________ Manufacturer, Lot number & expiration date___________________________________ Site, dose, and route of administration__________________________________________ Administered by____________________________________________________________

Second Dose

Date_____________________________ Manufacturer, Lot number & expiration date___________________________________ Site, dose, and route of administration__________________________________________ Administered by____________________________________________________________

Third Dose

Date_____________________________ Manufacturer, Lot number & expiration date___________________________________ Site, dose, and route of administration__________________________________________ Administered by____________________________________________________________

TOWN OF OLD SAYBROOK

DEPARTMENT OF POLICE SERVICES

YOUTH SERVICES DIVISION

6 Custom Drive Old Saybrook Connecticut 06475

 

Phone 860-395-3142 www.oldsaybrookpolice.com FAX 860-395-3142

AUTHORIZATION  

TO  OBTAIN/RELEASE JUVENILE RECORDS 

I  hereby  authorize  the  Old  Saybrook  Department  of  Police  Services  to  review my child’s documented police contacts and history for the purpose of providing the Old Saybrook Fire Department with an accurate assessment of my  child’s application as  they pursue membership with  the Old Saybrook Fire Department  Junior Division.    I understand  that  this  information may include arrest related incidents.   I  further authorize  the Old Saybrook Police Department’s School Resource Officer to obtain information from my child’s school records as part of this process.    I  understand  this  information may  include  confidential  records including school history, school progress reports and attendance.  I  understand  this  information  will  be  used  by  the  Old  Saybrook  Police Department  to  review  my  child’s  application  to  the  Old  Saybrook  Fire Department  Junior  Division.  I  also  understand  that  these  confidential materials will not be released to anyone else without my further consent or authorization.  This authorization will expire in 90 days.    Signature of Juvenile Date Signature of Parent or Legal Guardian Date

Old Saybrook Fire Department  

Standing Order 2012‐1  

Date Issued: April 17, 2012  

Titled: Sexual Harassment Policy  

 

POLICY 

The Old Saybrook Fire Co. No. 1  Inc. strives to provide members with an environment that  is 

free of all forms of illegal discrimination, including but not limited to sexual harassment.  Sexual 

harassment  in  connection  with  Fire  Company  activities  is  unacceptable  and  will  not  be 

tolerated.  Violations of this policy will be treated as serious disciplinary matters. 

 

DEFINITION OF SEXUAL HARASSMENT 

“Sexual  harassment”  refers  to  any  unwelcome  sexual  advance,  request  for  sexual  favors,  or 

other verbal or physical conduct of a sexual nature where:  

(1) Submission  to  such  conduct  is made  either  explicitly  or  implicitly  a  condition  of  an 

individual’s employment, membership, assignment, or good standing in the Company; 

(2) Submission to or rejection of such conduct by an  individual  is used as the basis of any 

personnel decision affecting such individual, including membership, good standing, work 

assignments, or promotion; 

(3) Such conduct is so severe or pervasive that it has the purpose or effect of unreasonably 

interfering with  the  individual’s work performance or creating an  intimidating, hostile, 

or offensive working environment. 

 

EXAMPLES OF SEXUALLY HARASSING CONDUCT 

The following are some examples of conduct that may constitute sexual harassment.  This list is 

not exhaustive.  Other conduct not specifically listed may also constitute sexual harassment. 

(1) Engaging  in  sexual  flirtation,  touching,  making  advances,  or  propositioning  another 

member, if that person has indicated or it is known such conduct is unwelcome. 

(2) Touching or grabbing any part of an employee's body after that person has indicated, or 

it is known, that such physical contact was unwelcome. 

(3) Verbal abuse of a sexual nature. 

(4) Making  graphic  or  suggestive  comments  about  an  individual’s  dress  or  physical 

appearance. 

(5) Using sexually degrading language to describe an individual. 

(6) Displaying  sexually  suggestive  materials  such  as  explicit  photographs,  drawings,  or 

videos. 

(7) Making  a  comment  or  spreading  a  rumor  that  embarrasses,  ridicules,  or  demeans  a 

person because of the individual’s gender or sexual orientation. 

(8) Threatening or implying, either explicitly or implicitly, that a member’s refusal to submit 

to  sexual  advances may  adversely  affect  the member’s  good  standing,  advancement, 

assigned duties, or any other privilege or condition of membership. 

(9) Continuing  to  ask  an  employee  to  socialize  on  or  off‐duty  when  that  person  has 

indicated s/he is not interested. 

(10) Inappropriately  using  electronic  communications,  including  electronic  mail,  social 

media, text messages, or the internet for any of the above purposes. 

 

MEMBER RESPONSIBILITIES 

(1) Members shall refrain  from engaging  in any activity or behavior which may constitute 

sexual harassment. As defined above sexual harassment refers to behavior or conduct 

of a sexual nature that is “unwelcomed.”  Thus, a consensual relationship between two 

members  would  typically  not  constitute  a  violation  of  these  sexual  harassment 

guidelines. 

(2) Any member who  believes  that  he  or  she  has  been  subjected  to  sexually  harassing 

conduct by another member, member of  the public, or member of another agency  is 

encouraged  to  directly  inform  the  offending  person  or  persons  that  such  conduct  is 

unwelcome and must stop. 

(3) If  the member  does  not wish  to  communicate  directly with  the  alleged  harasser  or 

harassers, or  if direct  communication has been  ineffective,  then  the person with  the 

complaint should immediately notify the Chief, Deputy Chief, or an Assistant Chief.   

(4) Any member who witnesses  sexually harassing  conduct, or who becomes  aware  that 

another member has been subjected to sexual harassment, is urged to promptly report 

the harassment to the Chief, Deputy Chief, or an Assistant Chief.   

(5) Any  member  who  engages  in  conduct  that  constitutes  sexual  harassment  shall  be 

subject to disciplinary action in accordance with Company By‐Laws, Standard Operating 

Guidelines, and Standing Orders. 

 

 

 

 

ADDITIONAL RESPONSIBILITIES OF OFFICERS 

(1) The  line officers and administrative officers are  leaders of the Company.  As such, they 

represent  the  organization  to  the membership,  the  public,  and  other  agencies with 

which the Company works.   

(2) All  line officers and administrative officers  shall make all  reasonable efforts  to ensure 

that the Company, its facilities and activities are free from sexual harassment.   

(3) Any line officer or administrative officer who witnesses or is made aware of allegations 

of sexual harassment by or against a member shall promptly report such information to 

the Chief, Deputy Chief, or an Assistant Chief.  

(4) Any line officer or administrative officer who engages in conduct that constitutes sexual 

harassment, or who upon being made aware of such conduct fails to promptly report it 

to the Chief, Deputy Chief, or an Assistant Chief, shall be subject to disciplinary action in 

accordance  with  Company  By‐Laws,  Standard  Operating  Guidelines,  and  Standing 

Orders. 

 

INVESTIGATION AND DISCIPLINE 

(1) Upon receiving a report or complaint of sexual harassment, the Chief shall thoroughly 

investigate the allegations. 

(2) Care will be taken to protect the  identity of the person with the complaint and of the 

accused  party  or  parties,  except  as  may  be  reasonably  necessary  to  successfully 

complete the investigation.  

(3) If the  investigation reveals the presence or occurrence of sexual harassment, the Chief 

shall impose appropriate discipline in accordance with the Company By‐Laws, Standard 

Operating Guidelines, and Standing Orders. 

(4) If  the  investigation  does  not  determine  the  presence  or  occurrence  of  sexual 

harassment,  the  person  with  the  complaint  and  the  accused  person  shall  be  so 

informed, with appropriate instruction provided to each.  

 

RETALIATION 

No  member  or  officer  shall  retaliate  against  another  member  for  complaining  about  or 

reporting sexually harassing conduct, or for participating in any investigation of such conduct.