1

East Valley Regional Cadet Program

The Cadet program has been developed to give its participants insight into the Firefighting profession as well

as help prepare its participants for a success in a variety of other situations. This program is a unique

opportunity; as such it requires commitment and dedication. To be clear of our expectations of Cadets this

document will outline some of the requirements and expectations that we have and disciplines we strive to

reflect.

Disciplines

Safety for ourselves and crew members

Personal Development

Team Building

Citizenship

Detailed Requirements and Expectations:

Come to every event rested and ready to learn

Show respect to your fellow Cadets and Instructors

Have fun and be safe

Ask questions

Hustle and work well with others in a team setting

Communicate with program coordinators should problems concerns arise

Example- calling/emailing if you are going to be late or need an excused absence

Cadets will address staff by rank and last name

Example: Captain Busboom, Engineer Dominguez, Firefighter Gill, Mr. Murphy

Cadet must be between the ages of 14 and 18 to participate in all events.

Cadets under 18 must have parent/guardian sign consent form.

Attend all events:

May have 2 excused absences over the 8 events

Must email or call 24 hours prior to event for an excused absence.

Tanya Morgan (480) 644-3882 Tanya.Morgan@mesaaz.gov

All excused absences will require an extended homework assignment.

One unexcused absence may lead to expulsion from program.

Maintain a 2.5 semester GPA in school to continue in the program.

We will require a mid-term copy of the progress report to show compliance.

Must have a 70% on all quizzes and pass all essay/presentation assignments.(on cadet related material)

2

If score is below 70%, Cadet must retake same quiz with an 80% or better and pass the assigned

essay/presentation. (on cadet related material)

The first part of the session will consist of a quiz followed by an explanation of the day activities. Read

homework assignments prior to each session.

****A Cadet parent and/or Cadet must contact the Program Administrator if there are any school suspensions, detentions or

law enforcement involvement with any Cadet program participant immediately upon discovery.****

Provide a sports/school physical or doctors physical to be eligible for program.

Completed by September 23, 2016, in order to participate in physical events

Cadets will be expected to participate in physical conditioning exercises at every Cadet event

and maintain a high level of physical fitness throughout the program.

Must complete 15 hours of volunteer time by 5/6/2017.

Volunteer Hours Report must be filled out and turned in for hours to count

Contact Volunteer Coordinator for volunteer opportunities

**Driving apparatus session requires a permit or license to be able to participate in that activity.**

Program Attire:

Cadet issued shirt is worn for all Cadet and Volunteer Events. Must be tucked in at all times

A Cadet’s uniform is not to be worn for other activities. This can be grounds for expulsion if

worn or used inappropriately.

Form fitting navy blue pants

Black belt

Black or white ankle high socks

Cadets must bring a pair of blue shorts and sneakers for mandatory physical training during all sessions

No hoop earrings are to be worn

Optional: Plain black, blue or white long sleeve shirt can be worn under Cadet shirt

Plain blue sweatshirt may be worn over the Cadet shirt during cold weather

**Penalties for not complying with expectations may be in the form of increased physical training for you and your teammates.**

Cadet Signature Parent/Guardian Signature

I have read and understand that failure to comply with these expectations may lead to expulsion from this program.

Signature Signature

EAST VALLEY REGIONAL CADET APPLICATION

How did you hear about this program?

Additional Required Documents

1. Progress Report: In order to verify your grade point average and to gain a better understanding of your overall academic performances please submit a progress report from your school when you are asked for them.

2. Medical Clearance/Sport Physical: Since physical activity is part of each Cadet session and the volunteer position you are applying for please submit medical clearance prior to starting this program.

Personal Information:

Name (Last, First, MI) Age: Date of Birth:

Address (Street/Apt#):

Address (City, State, Zip Code):

What school do you attend: What grade are you in?

Email Address: Shirt size: What type of community service have you been involved in (if any)?

Parent/Guardian Information:

Name of Parent/Guardian #1:

Phone # Email Address:

Name of Parent/Guardian #2:

Phone # Email Address:

City of Mesa Affiliations:

Have you ever been employed by or volunteered with the City of Mesa? No☐ Yes☐

If yes, please indicate what department and date when you worked/volunteered:

Have you ever been fingerprinted for City of Mesa? No☐ Yes☐

If yes, indicate date Click here to enter a date.

Are you related to any City of Mesa employee, volunteer, or member of City Council, Advisory Board or Commission? No☐ Yes☐

If yes name:

Dept/Board,Etc: Relationship to you:

Certification of Applicant: (Read your answers carefully before signing below) I hereby apply to volunteer with the City of Mesa. I understand that I will be expected to follow a mutually acceptable volunteer schedule and will promptly notify the program coordinator if I am unable to work as scheduled. I hereby certify that all answers to the questions on this application are true and I Understand and agree that any misstatement or omission of material facts contained in this application and materials attached may disqualify me or be cause for dismissal from volunteer service with the City of Mesa. I hereby expressly approve the City of Mesa to verify the accuracy of the education and work experience statements on this application. Prior to acceptance, fingerprinting for background checks through the Department of

Public Safety and the Federal Bureau of Investigation will be required. I understand that while volunteering I will be covered by the City of Mesa Worker’s Compensation policy under ARS statute 23-901.06. I also understand that it is my responsibility to keep Mesa Fire and Medical Department advised of any change of address, and once submitted, this form and all materials attached become the property of the Fire Department.

Cadet signature: Date:

Parent/Guardian signature: Date:

Parent/Guardian signature: Date:

Please use this page to tell us, in depth, why you want to be a Cadet and why you are interested in the fire service? (Please attach additional sheets if needed)

CITY OF MESA

FIRE AND MEDICAL DEPARTMENT

Non-Fire

Model Release (Photographs, Film, and Video)

For value received, the receipt and sufficiency of which is hereby acknowledged, I consent to and authorize the City of Mesa and its assignees and licensees to use, any and all photographs, motion pictures,

film, and video tape recordings taken of me, any reproductions of them in any form in any media, in connection

with the City of Mesa Fire and Medical Department training, promotional, and recruitment materials, including materials used for general fire safety awareness. I understand and agree that this consent may be revoked

upon providing thirty (30) days written notice to the Deputy Chief of Departmental Communications.

I consent to the use of my name in connection with these photographs, motion pictures, film, and video

tape recordings.

I release any and all claims in connection with the use of my photographs, motion pictures, film, video tape recordings, and name, and any reproduction thereof.

I waive any right that I may have to inspect and/or approve the use of my photographs, motion pictures, film, and video tape recordings, in connection with the City of Mesa Fire and Medical Department training,

promotional and recruitment materials.

Dated: _______________________

Name: ______________________________

Address: ______________________________

______________________________

Telephone: ______________________________

Signature: ______________________________

(NOTE: If the individual signing this Release is under the age of 18, individual’s parent/legal guardian must

sign the following):

I hereby certify that I am the parent/legal guardian of the individual who executed the foregoing

Release. Acting both for myself individually and on behalf of the individual, I consent to the execution of the

foregoing Release by this individual and the granting of the rights granted in this Release.

Parent/Legal Guardian

Name: ______________________________

Signature: ______________________________

CADET WAIVER OF RESPONSIBILITY AND RELEASE

NAME: _________________________________________________DATE: _______________

(Please Print)

ADDRESS: __________________________________CITY: ____________ZIP: ___________

PHONE: ( ) _________________

WAIVER OF RELEASE:

For, and in consideration of the privilege granted the undersigned by the City of Mesa, Arizona, in observing or participating in Fire Department activities or using the Fire Department facilities and equipment:

I, the undersigned, hereby waive any claim for any injury which I may either directly or indirectly sustain as the

result of observing or participating in any Mesa Fire and Medical Department activity, or as the result of any use of Department facilities and/or equipment, and hereby agree, for the privilege extended to me in being

permitted to observe or to participate in activities and to use the facilities and equipment to hold the City of

Mesa, their employees and/or officers, free from any liability of any kind and nature, for any injury or damage

which I may either directly or indirectly sustain through observing or my participation in any activity or in any use of the facilities or equipment.

This waiver and release shall be binding upon the undersigned and his/her heirs and assignees.

CADET SIGNATURE: _____________________________________________DATE: _______________

PARENT NAME: _________________________________________________DATE:_______________

PARENT SIGNATURE:____________________________________________DATE: _______________

ASSIGNED TO: East Valley Regional Cadet Program

WITNESSED BY MESA FIRE AND MEDICAL DEPARTMENT OFFICER IN CHARGE:

NAME: ______________________________________________ DATE: _________________________ (Sign Full Name and Employee Number)

I, (CADET NAME) know and understand that all patient information while

observing Mesa Fire and Medical Department Activities is confidential information that is not to be shared with anyone.

CADET SIGNATURE _______________________________________DATE_______________

PARENT SIGNATURE______________________________________DATE_______________

MESA FIRE AND MEDICAL DEPARTMENT

CADET EMERGENCY CONTACT INFORMATION 13 W. First Street

Mesa, AZ

CADET NAME: Last First Middle Address: Street - Apt # City State ZIP Code

( ) ( ) _____________ Home Phone Cell Phone Email Address

_______________________________________________________________________________________________

EMERGENCY CONTACT INFORMATION Name: Last First Middle Address: Street - Apt # City State ZIP Code

( ) ( ) Home Phone Cell/Message Phone Relationship

ARIZONA INTERSCHOLASTIC ASSOCIATION7007 North 18th Street, Phoenix, Arizona 85020-5552

Phone: (602) 385-3810

2016-2017 ANNUAL PREPARTICIPATION PHYSICAL EXAMINATION

The Preferred Health Care Partner of the Arizona Interscholastic Association

Name: Sex: Age: Date of Birth:

Height: Weight:% Body fat (optional):

Pupils:

Pulse:

BP:____/____ (____ /____,____/____)

Corrected: Y___ N___Vision: R20/_____ L20/_____

Normal Abnormal Findings Initials*

Medical

Musculoskeletal

Appearance

Lymph Nodes

Back

Pulses

Wrist/Hand/Fingers

Eyes/Ears/ Throat/Nose

Heart

Shoulder/Arm

Lungs

Hip/Thigh

Genitourinary †

Leg/Ankle

Hearing

Neck

Murmurs

Elbow/Forearm

Abdomen

Knee

Skin

Foot/Toes* Multi-examiner set-up only.† Having a third party present is recommended for the genitourinary examination.

NOTES:

Recommendations:

Name of Physician(Print/Type):

Address:

Signature of Physician:

FORM 15.7-B 03/12

Exam Date:

Phone:

, MD/DO/ND/NMD/NP/PA-C/CCSP

Cleared Without RestrictionNot Cleared For: All Sports Certain Sports Reason:

Equal_____ Unequal____

NextCare is the preferred partner of the AIA, it is not required you visit NextCare locations for your healthcare needs.

1-888-364-7502NextCareAZ.com

Apache Junction • 851202080 West Southern Ave., Suite #A1

Broadway Road

Mer

idia

n Ro

ad

Ironw

ood

Driv

e

Southern Avenue

60

Walgreens

Avondale • 8539213075 W. McDowell Rd., Suite #D106

W. McDowell Rd.

W. Van Buren St.

W. Indian School Rd.

N. D

ysart Rd.

N. Litch�eld Rd.

Fry’s

Casa Grande • 851221683 E. Florence Blvd., Suite #7

10

E. Florence Blvd.

E. Cottonwood Ln.

N. A

rizola Rd.

County Rd.

N. Verbena H

enness Rd.

99¢ Store

Bank ofAmerica

Walmart Chandler • 85224600 S. Dobson Road, Suite #C-26

Pecos Road Dob

son

Roa

dFrye Road

Chandler Blvd.

Glendale • 853065410 W. Thunderbird Road, Suite #101

W. Greenway Rd

N. 5

9th

Ave

N. 5

1st A

ve

N. 4

3rd

Ave

W. Thunderbird RdASU West Campus

Thunderbird Paseo Park

N. 3

5th

Ave

17N. 5

5th

Ave

H

Glendale • 8530210240 N. 43rd Ave., Suite #310240 North 43rd Avenue, Ste #3 Glendale, AZ 85302

W. Cactus Rd.

Peoria Ave.

N.

51

st

Ave

.

N.

43

rd A

ve

.

W. Dunlap Ave.

17

17

Glendale • 853059494 W. Northern Ave., Suite #101Peoria/Glendale9494 W. Northern Ave.

W. Olive Ave.

W. Northern Ave.N.

99

th A

ve

.

N.

91

st

Ave

.

W. Glendale Ave.

101

101

Target

Mesa • 852051066 N. Power Road, Suite #101

E. Brown Rd

Red MountainHigh School

N. P

ow

er

Rd

202

N. R

eck

er

Rd

E. McKellips Rd

Mesa • 852043130 E. Baseline Road, Suite #105

60

Baseline Road

N. L

inds

ay R

d.

N. V

al V

ista

Dr.

S. 3

2nd

St.

Dan

a Pa

rk

Mesa • 85203535 E. McKellips Road, Suite #101

McKellips Dr.

N. M

esa

Dr.

N. H

orne

LOOP202

Walmart

Cottonwood • 86326450 S. Willard Street, Suite #120

89AS. Calv

ary W

ayS.

Willa

rd St

.

W. Cottonwood St.

Airpark Rd.

89A

Glendale • 8530818589 N. 59th Ave., Suite #101

N. 5

9th

Ave

W. Union Hills Dr

Honeywell

101

N. 5

1st A

ve

N. 6

7th

Ave

Starbucks

Chino Valley • 86323474 State Highway 89

Safeway

89

89

W. Rd 1 N E. Rd 1 N

W. Rd 2 N

N. R

d 1

E

Walgreens

Center St.

Chino ValleyHigh School

Flagstaff • 860011000 N. Humphreys St., Suite #104

180

180

N. F ort Valley Road

N. H

um

phre

ys

Str

eet

W. Columbus Avenue

W. Desilva Avenue

Basha’sN

. Bea

ver S

tree

t

Flagstaff MedicalCenter

Lake Havasu City • 864031810 Mesquite Ave., Suite B

Kmart95 Mes

quite

Ave

.

N. M

cCul

loch

Blvd

.

Rivi

era

Blv

d

Capri Blvd.Library Ln

Civic Center Ln

95

Swan

son A

ve.

WheelerPark

Havasu RegionalMedical Center

Mesa • 852154401 E. McKellips Road, Suite #102

LOOP202

McKellipsVal V

ista

Gre

en�e

ld

McDowell

Walmart

Peoria • 8538220470 N. Lake Pleasant Rd., Suite #102

Rose Garden Ln.

Beardsley Rd.

Lake

Ple

asan

t Roa

d(9

9th

Ave.

)

(91s

t Av

e.)

101

20470 N. Lake Pleasant Rd.Suite 102Peoria, AZ 85382

LakePleasant Pkwy

Bashas

Walgreens

Phoenix • 850161701 E. Thomas Road, Suite #A104

51

E. Oak St.

E. Thomas Rd.

E. Osborn Rd.

N. 16th St.

N. 21st St.

N. 20 th St.

PhoenixChildren’sHospital

Phoenix • 850184730 E. Indian School Rd., Suite #211

N. A

rcad

ia Dr.

Indian School

N. 4

4th

St.

48th

St.

Arcadia H.S.

Safeway

Phoenix • 850218101 N. 19th Ave., Suite #A

8101 N. 19th Avenue, Ste. A Phoenix, AZ 85021

W. Northern Ave.

W. Orangewood Ave.N.

19

th A

ve

.

N.

7th

Ave

.

17

Albertson’s

The Preferred Health Care Partner of the Arizona Interscholastic Association

Phoenix • 8505020950 N. Tatum Blvd., Suite #19020950 N Tatum Blvd, Suite 190, Phoenix, AZ 85050

E. Deer Valley Rd.

N.

Ta

tum

Blv

d.

E. Rose Garden Ln.DESERT RIDGE

MARKET PLACE

101101

Scottsdale • 852607425 E. Shea Blvd., Suite #108

N. S

cott

sdal

e Rd

E. Shea Blvd

Harkins Theaters

N. H

ayden Rd

E. Mountain View Rd

N. 7

0th

St

101

N. 7

4th

St

Sun City • 853519745 W. Bell Road, Suite #1059745 W. Bell Road, Suite 105

Sun City, 85351

W. Union Hills Dr.

W Bell Rd.N. 9

9th

Ave

N. 9

8th

Ave

.

N. 9

1st

Ave.

W. Thunderbird Rd.

101

101

Tempe • 85281914 N. Scottsdale Rd., Suite #104

Curry Road

Scot

tsda

le R

oad

LOOP202

Jack inthe Box

Rura

l

Tucson • 857126238 E. Pima Street

Pima

SpeedwayW

ilmo

t10

6238 E. Pima St. Tucson

Circle K

Tucson • 857489525 E. Old Spanish Trail, Suite #101

E. Old Spanish Trail

E 22nd St

S H

arris

on R

d

9525 E. Old Spanish Trail Tucson

Target

Starbucks

Tucson • 857054280 North Oracle Rd., Suite #100

W. Wetmore Rd.

W. Prince Rd.

W. Miracle Mile

N. O

racl

e Rd

.

N. F

low

ing

Wel

ls R

d.

10

4280 N. Oracle Rd. Ste. 100Tucson, AZ 85705

77

Walgreens

W. Limberlast Dr.

Tucson • 857065369 S. Calle Santa Cruz, Suite #145

W. Ajo Way

W. Valencia Rd.

W. Drexel Rd.

W. Irvington Rd.

S. M

idva

le P

ark

Rd.

S. C

alle

San

ta C

ruz R

d.

10

86 86

5369 S. Calle Santa Cruz Suite 145, Tucson, 85706

Harkins

19

Tucson • 85719501 North Park Ave., Suite #110

E. 6th St.

Speedway Blvd.

University Blvd.

N. E

ucl

id A

ve.

10

N.P

ark

Ave

.

TUCSON

501 N. Park Ave., Ste. 110

MetroWildcat

Sedona • 863362530 W. SR 89A, Suite #A

89A

ya

W n

ore

H e

ulB

.rD t

acr

ae

B zt

utS

.d

R yb

giR

An

da

nte

Dr.

SEDONA

.tS

dralli

W.

S

.n

Ly

dn

aC

.S

S. C

alva

ry W

ay

COTTONWOOD

PRESCOTT PRESCOTT VALLEY

89A

89A

Green Ln.

Miller V

alley Rd.

Willo

w C

reek R

d.

N.

Gla

ssfo

rd H

ill R

d.

N.

Na

va

jo D

r.

N.

Ro

be

rt R

d.

N.

Win

dso

ng

Dr.

450 S. Willard Street, Suite 120 Cottonwood, AZ 86326(Arizona 89A at Willard Street)

2530 W. SR 89ASedona, AZ 86336(Arizona 89A & Andante Dr.)

2062 Willow Creek Rd.Prescott, AZ 86301(Green Ln. & Willow Creek Rd.)

3051 N. Windsong Dr.Prescott Valley, AZ 86314(E. Florentine Rd & Windsong Dr.)

69

E. Florentine Rd.

Prescott • 863012062 Willow Creek Road

89A

ya

Wn

ore

He

ulB

.rD

ta

cra

eB

ztut

S

.d

Ry

bgi

R

Andante

Dr.

SEDONA

.tS

dralli

W.

S

.n

Ly

dn

aC

.S

S. C

alva

ry W

ay

COTTONWOOD

PRESCOTT PRESCOTT VALLEY

89A

89A

Green Ln.

Miller V

alley Rd.

Willo

w C

reek R

d.

N. G

lassfo

rd H

ill R

d.

N. N

avajo

Dr.

N. R

obert

Rd.

N. W

indsong D

r.

450 S. Willard Street, Suite 120 Cottonwood, AZ 86326(Arizona 89A at Willard Street)

2530 W. SR 89ASedona, AZ 86336(Arizona 89A & Andante Dr.)

2062 Willow Creek Rd.Prescott, AZ 86301(Green Ln. & Willow Creek Rd.)

3051 N. Windsong Dr.Prescott Valley, AZ 86314(E. Florentine Rd & Windsong Dr.)

69

E. Florentine Rd.

Prescott Valley • 863143051 N. Windsong Drive

N. W

inds

ong

Dr.

N. R

ober

t Rd.

69

E. Florentine Dr.

E. Lakeshore Dr.

Phoenix • 850323229 E. Greenway Rd., Suite #102

51

E. Thunderbird Rd.

Greenway Rd.

E. Bell Rd.

N. 32nd St.

N. 40th St.

Food City

Phoenix • 850355920 W. McDowell Road

W. McDowell Rd.

W. Coronado Rd.

N. 59th Ave.

5920 W. McDowell Rd, Phoenix, AZ 85035

7-11

Walgreens

Surprise • 8537414800 W. Mtn. View Blvd., Suite #100

60

N. Reem

s Road

W. Mountain View Boulevard

Hampton Inn & Suites

Albertson’sMarket

W. Grand Ave

Colon n ade Way

1-888-364-7502NextCareAZ.com

The Preferred Health Care Partner of the Arizona Interscholastic Association