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2. First Name*
3. Last Name*
5. Phone Number*
6. Email Address*
8. Address1*
10. City*
11. State*
12. Zip*
14. Birthdate*
16. Parent's permission required to apply. (Unless applicant is 18)
18. Parent/Guardian Name*
20. Phone Number*
22. Address*
24. Emergency Contacts
26. Name*
27. Phone Number*
29. Name*
30. Phone Number*
32. Medical Information
34. Doctor*
35. Phone Number*
37. Hospital*
38. Phone Number*
40. Medical Conditions*
42. Allergies*
44. Do you take any medication?*
    -- Select One --YesNo
46. If yes, list the medication and what condition it is for.
48. Have you ever been arrested, ticketed, fined, etc? (felonies, traffic tickets, misdemeanors, etc.)*
    -- Select One --YesNo
50. If yes, please list the date(s) and what the charge(s) was/were:
52. What interests you the most about becoming involved with Draper City Fire Department?*
54. Please list other activities, in detail, that you are involved in. *
56. T-shirt Size*

    1. XS
    2. S
    3. M
    4. L
    5. XL
    6. 2X
    7. 3X
    8. 4X

    Please select your preferred t-shirt size. Each participant will receive a free t-shirt. 

58. Parental Consent
60. My daughter has my permission to join the AFFF program with Draper City Fire Department. I give my consent to allow her to be a participating member and do not hold the Draper Fire Department and First Responders or Draper City responsible for any actions caused by my daughter that is not under the direction of a program instructor.
62. Contract of Understanding
64. I and my daughter have read ALL of the AFFF Operating Guidelines and understand the guidelines set up to outline the purpose of the AFFF program. I and my daughter understand that AFFF serve as supporters of the Draper firefighters to learn the basics of firefighting and basic medical skills, along with prepping young women interested in pursuing firefighting as a career. I and my daughter understand that AFFF applicants are to follow all instructions from members of the DCFD and that the general standard of conduct is to act in the manner of a professional. I and my daughter understand that she is expected to be courteous and respectful of other members, and to all citizens, as she is representing the Draper City Fire Department. I and my daughter understand there is a "zero tolerance" policy regarding drug and alcohol use. I and my daughter understand that by signing this Contract of Understanding, we are declaring that any violation of the guidelines is grounds for immediate dismissal. I and my daughter understand that any acts that violate the guidelines and that are illegal by state law will be referred to the Draper City Police Department.
66. Acknowledge Receipt of Guidelines
68. I acknowledge that I and my daughter have received a copy of the Draper City Fire Department AFFF Program Guidelines (available at draperutah.gov/afff) and have reviewed them prior to signing this application.
70. Applicant Signature and Date*
72. Parent Signature and Date*
74. Fire Chief Approval and Acknowledgement of Applicant and Parent's Receipt of Draper City Fire Department AFFF Program Guidelines.
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field