Scarborough Fire Department - Town of Scarborough

STATEMENT OF PHYSICIANI, _______________________________, am the physician for person named above.I have read the above-described activities in the job-related physical fitness testfor the position of Firefighter, and certify that to my knowledge no physicalillness or condition exists that would render the described activities unsafe orinadvisable for the applicant.Date: _______________________________________________________Physician Signature____________________________Printed name of PhysicianRELEASEI hereby release, discharge and waive all rights of action against the Town ofScarborough and its agents and employees which I or my heirs, successors orassigns have or might have by reason of any personal injury, death or propertydamage resulting from my participation in the above described physical abilitytest, which I agree to take voluntarily and without coercion or duress.DATE: _________________________________________________________Signature of Firefighter/Applicant__________________________________Printed name of firefighter/ApplicantI personally witnessed the applicant sign this release in my presenceDATE: _________________________________________________________Signature of Scarborough Fire RepresentativeFor Department Use Only: Maximum Allowable Time for Timed Tasks: 05:30Test Date: ______Total Time: _______+ Penalty _______ = Test Time: _______Claustrophobia Test: pass fail Ladder Climb: pass failCandidate has passed failed the SFD physical ability test__________________________________Signature of Scarborough Fire Representative__________Date7