City of Lake Geneva
Explorer's Application

Lake Geneva Fire Department
730 Marshall Street
Lake Geneva, Wisconsin 53147

Directions: This application contains the following eight documents to be completed by filling in the blanks then print and sign in blue or black ink:

1.          Personal Information;
2.          Criminal & School History: Be honest - we check;
3.          References;
4.          Authorization for Medical Treatment;
5.          Emergency Notifications;

6.          Release of Civil Liability;
7.          Statement of Confidentiality; and

8.          Talent Release.

The applicant and the applicant’s parent or guardian (if the applicant is under eighteen years of age) must sign the pages for References,
Authorization for Medical Treatment, Release of Civil Liability, Statement of Confidentiality, and Talent Release in the presence of a Notary.
The notary must stamp these pages.

PERSONAL INFORMATION

First Name: Middle Initial:   Last Name:

Address:

City:   State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Date of Birth (mm-dd-yyyy):   Place of Birth - City:   State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Home Phone Number: 

Mobile Number:

Pager / Beeper Number:

Race: CHOOSE ONE Hispanic American Indian Alaska Native Asian Black or African American White Native Hawaiian or other Pacific Islander Sex: CHOOSE ONE Male Female

Eye Color: CHOOSE ONE Amber Blue Brown Gray Green Hazel Heterochromia Red/Pink (Albinism) Violet Hair Color: CHOOSE ONE Auburn Black Blonde Brown Grey / White (Albinism) Red

Social Security Number:

Drivers License Number :

School:

Parent or Guardian: 

Address:

City:   State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Emergency Contact Number:

CRIMINAL AND SCHOOL HISTORY

Have you ever been suspended or expelled from any school?  CHOOSE ONE Yes No

Yes, Explain in detail:

Have you ever sold or consumed any illegal drugs? CHOOSE ONE Yes No

Yes, Explain in detail (what type of drug, how much was used, when was the last time the drug was used):

Have you ever been arrested or charged with ANY crime EVER? CHOOSE ONE Yes No

Yes, explain in detail (the charge, final court disposition, arresting police department, case number, and court case number):

REFERENCES

Please list three references, other than relatives, that you have known for at least two years. This is to determine your character, experience, personality, and other qualities.

Name #1: 

Address:

City:   State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Contact Number:

Name #2: 

Address:

City:   State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Contact Number:

Name #3: 

Address:

City:   State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Contact Number:

Your acceptance as a member of the Lake Geneva Fire Department Explorer Program is based on your accurate completion of this application, criminal history,
and overall good character. Membership is a privilege, not a right.
I affirm that this application contains no misrepresentations, falsifications, omission, or concealment of material fact. I also affirm that the information given by me
is true and complete to the best of my knowledge. I am aware that any falsifications will terminate my application for membership in the Lake Geneva Fire Explorers.
Signature Of Applicant ______________________________________________ Date ____/____/______
Parent or Guardian if under 18: ______________________________________________ Date ____/____/______
Authorization For Medical Treatment
 I, ____________________________________  as the legal parent / guardian of _________________________________  do hereby request the
City of Lake Geneva, the Lake Geneva Fire Department, or the Lake Geneva Fire Explorers notify the following persons in the event of an illness, injury,
or emergency. If the listed persons cannot be reached or if the minor child listed above requires immediate medical treatment, I hereby request and authorize the
City of Lake Geneva, the Lake Geneva Fire Department, their employees and Lake Geneva Fire Explorers to seek immediate medical treatment and to transport
or seek transportation by ambulance if necessary, of said minor child to a medical facility for any treatment deemed to be medically necessary for the health,
safety, or welfare of the child.
I hereby agree to indemnify, save and hold harmless the City of Lake Geneva, the Lake Geneva Fire Department, the Lake Geneva Fire Explorers, employees,
agents or assignees from any and all rights, actions, claim, causes of action, suits, losses, damages, judgments, claims, cost, or expense of any kind as well as
attorney’s fees on appeal, which may result from or occur as a result of or in connection with the participation of the previously listed child in any program
sponsored by or promoted by the City of Lake Geneva, the Lake Geneva Fire Department or the Lake Geneva Fire Explorers. I additionally agree to be
responsible for any cost associated with or resulting from said medical treatment and transportation.

EMERGENCY NOTIFICATIONS

Name #1: 

Address:

City:   State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Contact Number:    Other Contact Number:

Name #2: 

Address:

City:   State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Contact Number:    Other Contact Number:

Name #3: 

Address:

City:   State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Contact Number:    Other Contact Number:

Local Hospital Preference:

Allergies / Medications:

Current or Required Medications:

Physician’sName #3: 

Address:

City:   State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Flordia Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip:

Contact Number:    Other Contact Number:

Insurance Company:  Policy Number:

RELEASE OF CIVIL LIABILITY
In considerations of the privileges being granted to_______________ by the Lake Geneva Fire Explorers, the Lake Geneva Fire Department,
and the City of Lake Geneva to use the facilities in the Lake Geneva Fire buildings and benefit from participation in the Lake Geneva Fire Explorers.
I hereby assume all risk of personal injury, death, and property damage or loss from whatever causes arises while the above named child is
approaching, entering, using, leaving, or being about any property of the City of Lake Geneva. While using, intending to use or being granted this privilege,
including but not limited to being transported from or to any off campus site location while participating in this program, I release the City of Lake Geneva,
the Lake Geneva Fire Department, and the Lake Geneva Fire Explorers, it’s officers, employees, agents, assignees and servants from any liability, or
contribution to such liability, while using these privileges.

I further indemnify and hold harmless the Lake Geneva Fire Department, the City of Lake Geneva, and their employees, assignees, agents and the
Lake Geneva Fire Explorers from and against any and all damages, suits, claims, personal injury, including death, attorney’s fees and attorney’s fees on appeal.

It is further understood and agreed by me that the Lake Geneva Fire Explorers, Lake Geneva Fire Department, and the City of Lake Geneva may revoke this privilege at any time.

Signature Of Applicant ______________________________________________ Date ____/____/______

Parent or Guardian if under 18: ______________________________________________ Date ____/____/______


STATEMENT OF CONFIDENTIALITY
Wisconsin Statues prohibit the unauthorized disclosure of information from particular fire and medical records. I understand that the unauthorized disclosure of this
or other protected information could lead to my dismissal from the Lake Geneva Fire Explorers program and/or possible criminal penalties.

As an Explorer for the Lake Geneva Fire Department, I understand that I will be held accountable under law for the disclosure of any and all information related to fire
and EMS matters or confidential cases.

I further understand that I will not release any information obtained as a result of my participation in the Lake Geneva Fire Explorers unless specifically authorized in
advanced by a representative of the Lake Geneva Fire Department.

I further understand that as an Explorer, I shall not represent myself as a firefighter, take any action that might lead a reasonable person to believe that I am a firefighter,
or take any job related action not specifically authorized or requested by a member of the Lake Geneva Fire Department. I fully understand that such actions may lead
to criminal prosecution for unauthorized display of fire insignia and/or impersonating a certified firefighter or EMS provider.
Signature Of Applicant ______________________________________________ Date ____/____/______

Parent or Guardian if under 18: ______________________________________________ Date ____/____/______