Fillable Course Registration Form printable pdf download

South Carolina Fire Academy - Course Registration Form

Course Type:

Public

Industrial

other _________________________________________________________________________

Course Code - Section Number

Course Name

Dates

Location

Resident

Yes, I need a dorm room - arrival date:__________departure date:__________

I also need ____ night(s) - date(s): ____________

Courses

Note:

Payment must be submitted with registration for all nights requested. Evening meals are not available.

Check here if any

Only

No, since I live within 50 miles, I don't need a dorm room

information has

changed

NOTE:

This form must be completed and accompanied by the proper registration fees, or it will be returned without being processed. Checks should be made payable to

the State of South Carolina. Forms and fees must be received at least two weeks prior to the class start date. Some courses may require earlier registration

(form cannot be processed without SSN)

Social Security Number: _______________________________

male

female

date of birth: _______________ age: _______

Last name: _____________________________________________________ First name: _______________________________________________ Initial: _______

Mailing address:_______________________________________________________________________ e-mail: _____________________________________________

City: _____________________________________________________ State: _____________ Zip: ______________ County: ______________________________

Daytime phone #’s: Work: ___________________________________________________ Home: _____________________________________________________

Fire Dept. or Organization __________________________________________________________

Status: (check only one)

Public Fire

Industrial

FDID#: __________________ Dept. phone ___________________________________________

1. paid only

5. brigade member

2. paid and volunteer

Notice:

6. fire protection-

It is the policy and practice of the South Carolina Fire Academy to make all testing and

3. volunteer only

related company

certifying services available to all of its constituents without regard to race, religion, color, na-

tional origin, sex, or age, except where sex or age is a bonafide occupational qualification.

4. public safety officer

7. other

Agreement and Waiver / Liability Release

•

In consideration for participating in South Carolina Fire Academy training, I hereby release, indemnify, and covenant not to sue the South Carolina Fire Academy, S.C.

Department of Labor, Licensing and Regulation, The State of South Carolina, their officers, agents or employees (Releasees) as well as any other students or

instructors from any and all liability, claims, cost and causes of action arising out of or related to any property damage or personal injury, including death, that may

be sustained by me, while participating in such activity, or while on the premises owned, leased or used by Releasees. I acknowledge the training involves physically

strenuous activities in which I am capable of fully participating. I know of no physical or mental condition that would preclude my full participation in the training.

•

I certify that the information on this registration form is correct. I agree to abide by the rules, policies, and regulations of the South Carolina Fire Academy. I

understand that falsifying information or violating rules or procedures may result in me being denied admission to the course and/or loss of course credit.

•

I authorize the release of any information concerning my enrollment and completion of all South Carolina Fire Academy courses to me, my fire chief, or my

department training officer.

•

I understand that the South Carolina Fire Academy is not authorized to provide travel, medical, or health insurance, I verify that I or my agency maintain appropriate

and necessary coverage, and I understand that I or my agency will be responsible for any medical expenses that I may incur as a result of my participation in this

program.

•

I understand that the nature of the tasks I may perform while involved in this training may require a high degree of physical fitness, agility, and dexterity, and that this

may include rigorous exercises which require physical fitness, strength, and stamina. I am fully aware of the risks and hazards associated with fire, rescue and

hazardous materials training, including but not limited to burns, heat stroke, heart attack, heat exhaustion, falls and other related injuries, and I choose to voluntarily

participate in the activity with full knowledge that said activity may be hazardous to me and my property.

•

In signing this release, I acknowledge that I have read and understand the Release: and that I am at least 18 years of age and fully competent and a

member of a legally organized fire department, fire brigade, fire related business or emergency response organization.

•

By registering for this course, I hereby give the South Carolina Fire Academy permission to reproduce and publish my name and/or photographic

likeness.

Signature - form must be signed by student

Date

Fire Chief or Designee

Registration Use Only

Received from: